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EQUILIBRIUM    AND 
V  ERTIG  O 


By 

ISAAC  H.  JONES,  M.A.,  M.D. 

Laryngologist,  Philadelphia  General  Hospital;  histructor  in  N euro-Otology ,  JJ niversity  of 

Peimsylvania  Medical  School;  Associate  American  Otological  Society; 

Major,  M.R.C.,  U.  S.  Army 


lilTH  AN  ANALYSIS  OF  PATHOLOGIC  CASES 
By 

LEWIS  FISHER,  AI.D. 

Laryngologist  and  Otologist,  Mt.  Sinai  Llospital,  Philadelphia 


ADOPTED  AS  STANDARD  FOR 

MEDICAL  DIVISION,  SIGNAL  CORPS.  AVIATION  SECTION 

BY  SURGEON  GENERAL,  AND 

CHIEF  SIGNAL  OFFICER, 

U.  S.  ARMY 


JIITH  ISO  ILLUSTRATIONS 


PHILADELPHIA  &  LONDON 
J.  B.  LIPPfNCOTT  COMPANY 


Q 


Copyright,  191S 
Hy  J.  B.  I  ippixcoTT  Company 


PUBLISHED    Jl  NE,    191S 

Eeprixted  September.  1918 


Y^v^.a 


Electrotyped  and  Printed  hy  J.  B.  Lippincott  Company 
The  Washington  Square  Press,  Philadelphia,  V .  S.  A. 


DEDICATED 

WITH    AFFECTIONATE    REGARD, 

TO 

DR.  CHARLES  K.  MILLS, 

DR.  B.  ALEXANDER  RANDALL, 

DR.  T.  H.  WEISENBURG. 


PREFACE 

The  studies  presented  in  this  book  were  originally  undertaken 
at  the  suggestion  of  Dr.  T.  H.  Weisenburg.  Most  of  the  work  was 
done  at  the  University  of  Pennsylvania  under  the  guidance  of 
Dr.  B.  Alexander  Randall,  whose  encouragement  will  always  be 
alfectionately  remembered.  A  sub-department  of  "Neuro-Otol- 
ogy"  was  created,  in  which  Dr.  Lewis  Fisher,  Dr.  Seth  A.  Brumm 
and  the  writer  conducted  experiments  which  constituted  the 
foundation  for  this  study.  Acknowledgment  is  made  of  the 
sympathetic  co-operation  and  assistance  of  Dr.  Charles  K. 
Mills,  who,  with  Dr.  Weisenburg,  guided  us  from  the  Neurologic 
standpoint;  and  also  to  Dr.  William  G.  Spiller  for  his  unstinted 
interest  and  advice.  The  Neurologic  Chapters,  XII  and  XIII, 
constitute  the  presentation  of  the  direct  teachings  of  Drs.  Mills 
and  Weisenburg. 

On  the  Otologic  side  sincere  thanks  are  due  to  Dr.  George  E. 
Shambaugh  and  to  Dr.  Eugene  U.  Lewis  for  many  invaluable  sug- 
gestions, and  on  the  Surgical  side  to  Dr.  Cliarles  H.  Frazier. 

The  studies  of  the  relation  of  the  ear  to  the  eye  were  undertaken 
with  the  help  of  Dr.  II.  Maxwell  Langdon,  during  a  period  of  four 
years.  The  studies  in  syphilis  were  originally  undertaken  in 
co-operation  with  the  late  Dr.  Alexander  A.  Uhle  and  later  with 
his  associate,  Dr.  William  H.  Mackinney. 

The  dissections  of  the  brain  were  made  by  the  eminent  ana- 
tomist. Dr.  Addinell  Hewson,  and  the  stereoscopic  photographs,'^' 
although  taken  by  the  author,  were  made  possible  by  the  equip- 
ment and  expert  guidance  of  Dr.  Matthew  II.  Cryer. 

The  moving  pictures  were  taken  and  arranged  through  the 
courtesy  of  Mr.  S.  Lubin,  who  has  shown  a  most  sincere  interest 
in  the  advancement  of  the  use  of  moving  pictures  as  a  means  of 
medical  teaching  and  research. 


*  A   duplicate   set    will    he   found   in    the   hack   of  the   book   for   use   with   the 
stereoscope. 


vi  PREFACE 

The  diagrams  and  photographs  were  perfected  by  the  painstak- 
ing work  of  W.  H.  Hoedt. 

Thanks  are  due  to  Emilie  Austin  Jones  for  original  suggestions 
regarding  the  outline  of  the  book  and  the  arrangement  of  the 
chapters,  and  to  Lillie  B.  Ljnm  for  years  of  daily  elTort  in  syste- 
matizing the  numberless  details  incidental  to  the  production  of 
this  book. 

It  would  be  difficult  to  express  full  appreciation  to  Dr.  Lewis 
Fisher,  who  has  devoted  j^ears  of  original  work  to  this  subject, 
not  only  for  writing  the  chapter  on  Pathologic  Cases  but  for  his 
intimate  daily  co-operation  in  the  writing  of  the  entire  book. 

Thanks  are  expressed  to  the  publishers,  J.  B.  Lippincott  Com- 
pany, not  only  for  their  courtesy,  but  because  of  the  enthusiasm 
and  spirit  with  which  they  supported  this  attempt  to  introduce 
a  somewhat  new  subject. 

Isaac  H.  Jones 

Office  of  Chief  Surgeon, 

Aviation  Section,  S.  C,  U.  S.  Army, 

Washington,  D.  C. 

April,  191S 


CONTENTS 

PART  I 
THE  PRACTICAL  USES  OF  A  STUDY  OF  THE  INTERNAL  EAR 

PAGE 

I.  Neuro-otology 3 

The  intimate  relation  of  the  ear  to  the  rest  of  the  body  through  the 
nervous  system.  The  ear  is  a  double  organ — the  organ  of  hearing  and 
the  organ  of  balance.  The  organ  of  balance  is  of  much  greater  impor- 
tance to  the  clinician  than  the  organ  of  hearing.  The  new  ear-  tests  have 
been  developed  by  the  Vienna  School  of  Otologists,  notably  Robert 
Barany.  Every  portion  of  the  body  musculature  is  affected  by  stimula- 
tion of  the  ear;  this  is  because  of  nerve  pathways  connecting  all  these 
parts  with  the  ear.  When  ear-stimulation  produces  normal  responses  it 
demonstrates  that  these  pathways  are  intact ;  absence  of  normal  responses 
indicates  an  impairment  by  disease  of  these  pathways.  The  value  of  co- 
operation of  otologists  with  those  in  other  branches  of  medical  work. 

n.  The  Ear  and  the  General  Practitioner 10 

The  kinetic-static  labyrinth  is  the  sense-organ  of  equilibration.  Equili- 
bration is  made  possible  by  harmonious  co-operation  of  sight,  muscle- 
sense  and  preeminently  the  balance-sense  of  the  ear.  Vertigo  is  essen- 
tially an  ear  study.  Vertigo  may  be  caused  by:  1.  Involvement  of  the 
ear-mechanism  by  a  lesion  in  the  ear  itself;  2.  Involvement  of  the  ear- 
mechanism  by  a  lesion  affecting  the  intracranial  jjathways  from  the  ear; 
3.  Involvement  of  the  ^ar-mechanism  by  ocular  disturbance;  4.  Involve- 
ment oT  the  ear-mechanism  by  cardiovascular  disturbance.  5.  Involve- 
ment of  the  ear-mechanism  by  toxaemias  from  any  organ  or  part  of  the 
body.  By  ear-mechanism  is  meant  the  entire  "equilibratory  apparatus," 
of  which  the  ear  is  the  "sense-organ."  The  new-ear-tests  enable  us  to 
analyze  the  apparatus  I'esponsible  for  vertigo  and  provide  a  method  of 
approach  in  determining  the  cause  of  the  vertigo.  L  Ear  lesions.  The 
urgent  need  of  recognizing  pathologic  conditions  of  the  internal  ears. 
Non-inflammatory  conditions  of  the  labyrinth;  inHammatory  conditions. 
Dizziness  should  always  cause  the  physician  to  consider  the  ear  at  once. 
2.  Intracranial  lesions  involving  the  pathways  from  the  ear;  tumor, 
hemorrhage,  thrombosis,  infarct,  abscess,  gumma,  tubercle,  specific 
neuritis,  multiple  sclerosis,  syringo-myelia,  jjolio- encephalitis  and 
meningitis.  3.  Involvement  of  the  ear-mechanism  by  ocular  disturbance, 
either  through  the  eye-muscle  nuclei  or  through  association  fibres  from 
the  cuneus  to  the  cortical  terminus  of  the  fibres  from  the  ear  in  the 
posterior  portion  of  the  first  temporal  convolutions.  4.  Cardiovas- 
cular; ischgemia  or  congestion.  5.  Toxemias.  Evanescent  toxemias 
which  have  produced  no  degeneration  of  the  cellular  element  within 
the  internal  ear  or  its  intracranial  pathways.  Toxemias  which  have 
produced  a  definite  impairment.  Ear-examination  does  not  determine 
everything  whatsoever  that  has  to  do  with  vertigo  but  it  brings  order 
out  of  chaos  and  makes  possible  accurate  diagnosis  and  intelligent 
treatment. 

III.  The  Ear  and  Aviation 24 

Without  functionating  internal  ears  it  is  impossible  for  an  individual  to 
be  a  good  bird-man.  U.  S.  Army  standards  for  examination  of  candi- 
dates for  the  Aviation  Service.  Official  blanks.  The  turning  tests 
quickly  separate  the  obviously  fit  from  the  unfit.  In  "border  line"  cases, 
the  caloric  test  decides.  It  is  obvious  to  the  candidate  himself,  that  if 
he  is  deficient  in  his  ear  balance-sense  he  is  not  only  a  danger  to  the 
Service,  but  is  also  unnecessarilv  imperiling  his  own  life  when  he  attempts 
to  fly. 

vii 


viii  CONTENTS 

IV.  The  Eak  and  Seasickness 34 

"Mai  de  iner"  is  a  phenomenon  resulting  from  movements  of  the  endo- 
lymph  within  the  internal  ear.  Old  theories  and  old  "eures."  Proofs 
that  seasickness  is  an  ear  i)henomenon.  The  mechanism  which  produces 
seasickness.     The  question  of  prevention  and  treatment  of  seasickness. 

V.  The  Ear  ix  Syphilis 47 

The  new  tests  of  the  ^Tli  Nerve  have  brought  to  the  attention  of  the 
syphilologist  a  method  of  furnishing  data  in  the  study  and  treatment  of 
syphilis:  1.  In  the  early  diagnosis  of  syphilis.  2.  In  the  early  diagnosis 
of  syphilis  of  the  nervous  system.  3.  In  the  early  recognition  of  neural 
recurrences.  4.  In  estimating  therapeutic  activity  and  efficiency.  5.  In 
heljiing  to  determine  whether  a  case  of  syphilis  is  completely  cured. 

VI.  The  Ear  and  the  Neurologist 53 

Intimate  relation  of  the  ear  to  the  entire  nervous  system.  Value  of 
ear- examination  to  the  neurologist.  Differential  diagnosis  between 
labyrinth  and  intracranial  lesions;  IS  differential  jxjints.  Intracranial 
localization.  Outline  of  method  of  analj-sis  of  abnormal  responses  to 
ear-stimulation.  The  value  of  eye-examination  to  the  neurologist  is 
recognized;  ear- examination  has  a  similar  usefulness,  and  in  fact  more 
definite  information  can  as  a  rule  be  had  from  ear-tests  than  from  eye- 
examination.  The  ear-examination  is  not  intended  to  "make  a  diagnosis'' 
of  intracranial  lesions;  the  neurologist,  however,  needs  to  be  familiar 
with  methods  of  ear-examination  in  order  to  interpret  the  significance 
of  the  responses  to  the  ear-tests. 

VII.  The  Ear  and  the  Surgeon 59 

No  phase  of  surgery  more  difficult  in  diagnosis  than  intracranial  localiza- 
tion. The  additional  data  obtained  by  ear-examination  have  proven  of 
value  to  the  surgeon  in  lesions  of  pons,  cerebellum,  cerebello-pontile  angle 
and  cerebral  crura.  Normal  responses  to  ear-stimulation  indicate 
normal  posterior  fossa  and  brain-stem.  Value  of  ear-tests  in  preventing 
unnecessary  operations.  No  operation  ujjon  the  brain  should  be  under- 
taken without  giving  the  patient  the  benefit  of  an  ear-examination. 

VIII.  The  Ear  and  the  Ophthalmologist 62 

The  ears  are  continually  sending  tonic  impulses  to  the  eyes,  maintaining 
ocular  fixation.  Impulses  from  the  right  ear  pulling  the  eyes  to  the  left, 
and  impulses  from  the  left  ear  pulling  the  eyes  to  the  right;  the  combined 
influence  holds  the  eyes  stead}'.  Physiologic  evidence,  electrical  stimu- 
lation. Pathologic  evidence.  Experimental  stimulation  of  the  ear  can 
produce  at  will  any  form  of  ocular  rotation.  Practical  uses  of  ear-tests. 
In  the  study  of  eye-muscle  palsy;  determination  of  the  degree  of  paresis 
or  paralysis.     The  anah'sis  of  the  cause  of  spontaneous  nystagmus. 

IX.  The  Internal  Ear  and  the  Otologist 67 

Two  misconceptions:  1.  That  examination  of  the  internal  ear  is  neuro- 
logic work.  2.  That  it  is  enormously  difficult.  Such  a  study  is  not 
neurologic  and  is  as  simple  as  as  any  other  form  of  ear  examination. 
Value  of  tests  of  the  vestibular  labyrinth .  1.  In  routine  ear  examination. 
In  determining  function  of  cociilea,  presumptive  evidence.  In  deter- 
mining function  of  kinetic-static  labyrinth,  absolutely  essential.  2.  To 
aural  surgeon.  These  tests  are  only  means  of  determining  whether  or 
not  to  operate  on  labj'rinth.  3.  The  larger  field  of  intracranial  study. 
Analogy,  the  ophthalmologist  does  not  consider  himself  fully  equipped 
unless  he  understands  the  intracranial  aspects  of  eye-examination. 


CONTEXTS  ix 

PART  II 

THE  STUDY  OF  THE  INTERNAL  EAR 

•     X.  The  Develoiment  of  N euro-otology 73 

The  Ancients  recognized  that  turning  an  incUviduai  caused  him  to  he 
dizzy,  3'et  it  was  not  until  the  past  century  that  this  was  recognized  as 
an  ear  phenomenon.  The  work  of  Flourens,  Purkinji,  Meniere  and 
Hoyjes  was  made  practical  by  the  studies  of  Barany,  Neumann,  Ihittin 
and  Alexander.  liarany  especially  has  extended  this  study  by  demon- 
strating the  close  association  of  the  ear  and  the  central  nervous  system. 

XI.  Anatomic    and    Phy.siologic    Consider.ations    of    the    Labyrinth    and 

Vm  Nerve 76 

Knowledge  of  structure  and  function  of  internal  ear  necessary  in  order 
to  understand  the  ear- tests.  Anatomy:  Embryology.  Bony  labyrinth; 
membranous  labj-rinth.  Perilymjjh;  endolyini)h.  Divisions  of  mem- 
branous labyrinth,  cochlea,  utricle,  saccule  and  three  .semicircular  canals. 
Three  types  of  sense-organs,  the  organ  of  Corti,  the  macula  and  the 
crista.  The  fibres  from  the  organ  of  Corti  form  the  cochlear  portion  of 
the  VIII  Nerve.  Fibres  from  the  two  macula?  and  three  crista^  form  the 
vestibular  portion  of  the  VIII  Nerve.  Physiology:  End-organ  is  a  hair- 
cell  stimulated  by  wave  impulses.  In  cochlea,  wave-impulses  are  received 
from  external  world.  In  vestibule  and  canals,  wave- impulses  are  pro- 
duced by  movement  of  the  fluid  within  the  labyrinth  itself.  1'hree 
functions  of  internal  ear:  L  Hearing — cochlea.  2.  Static-utricle  and 
saccule,  ^i.  Kinetic-utricle,  saccule  and  tlie  semicircular  canals.  Proof 
that  the  lymph  does  move  within  the  semicircular  canals.  Explanation 
of  reason  for  the  association  within  one  organ  of  two  separate  organs — 
hearing  and  balance. 

XII.  Medulla  Oblongata,  Pons  and  Cerebellum 91 

Anatomic  and  physiologic  considerations.  The  medulla  oblongata,  pons 
and  cerebral  crura  constitute  the  l)rain-stem.  Above  and  behind  the 
brain-stem  is  the  cerebellum,  which  is  connected  with  the  brain-stem 
by  three  ])airs  of  peduncles.  The  superior  cerebellar  peduncles  enter 
the  cerebral  crura,  to  be  distributed  to  the  cerebrum.  The  middle  cere- 
bellar peduncles,  the  largest  of  all,  connect  the  cerebellum  with  the  pons, 
and  in  fact  constitute  the  larger  portion  of  the  pons  itself.  The  inferior 
cerebellar  peduncles  connect  the  cerebellum  with  the  medulla  oblongata. 
The  fibres  constituting  the  peduncles  enter  the  cerebellar  nuclei;  from 
these  nuclei  are  projection  fibres  to  the  cerebellar  cortex.  Cereljellum 
consists  of  a  central  portion,  the  vermis,  and  two  lateral  hemispheres. 
The  vermis  presides  over  the  trunk.  The  right  cerebellar  hemisphere 
has  to  do  exclusively  with  the  right  upper  extremity  and  the  right  lower 
extremity;  the  left  cerebellar  hemisphere  presides  exclusively  over  the 
left  upper  extremity  and  the  left  lower  extremity. 

XIII.  Cerebellar  Localization 114 

Presentation  of  views  of  Mills  and  \\'eisenburg.  Cerebellum  is  essentially 
a  motor  organ  and  is  concerned  with  supplying  .synerg}-  for  bodily  move- 
ments. Scheme  of  localization  in  cerebellar  cortex.  Symptomatology  of 
lesions  of  cerebellum  itself,  superior  cerebellar  peduncle,  middle  cere- 
bellar peduncle,  inferior  cerebellar  peduncle  and  cerebello-pontile  angle. 

XIV.  Tracts  of  the  Auditory  Apparatus  and  of  the  Vestibular  Apparatus.    122 

Fibres  from  the  horizontal  canal  have  a  separate  pathwaj'  from  the 
fibres  from  the  vertical  canals.  Fibres  from  the  vertical  semicircular 
canals  ascend  into  the  pons.  Fibres  from  the  horizontal  canal  are  limited 
to  the  medulla  oblongata.  The  fibres  responsible  for  nj'stagmus  are 
separate  from  those  responsible  for  vertigo.  The  fibres  conveying  the 
impulses  jiroducing  vertigo  go  through  the  cerebellum  en  route  to  the 
cerebrum.  Evidence  on  which  these  pathways  are  based.  Tracts  in 
detail. 


X  CONTENTS 

XV.  N'estibulak  Nystagmus 136 

Tlie  slow  coniponcnt  of  nystagnuis  is  caused  by  ear-stimulation;  the 
quick  conii)onent  by  inii)ulses  from  cerebrum.  Tracts  in  detail:  1. 
Vestibulo-ocular  (for  slow  comj)onent);  (a)  Horizontal  canal  tracts; 
(b)  Vertical  canals  tracts.  2.  Cerebro-ocular  (for  quick  component). 
Planes  of  nystagmus-horizontal,  frontal  and  sagittal.  The  horizontal 
canal  produces  horizontal  nystagmus.  Vertical  canals  produce  nystagnuis 
in  the  frontal  plane  when  they  are  influenced  in  the  frontal  i)lane.  \  erti- 
cal  canal.^  produce  nj'stagmus  in  the  sagittal  plane  when  they  arc  influ- 
enced in  the  sagittal  plane.  Methods  of  producing  vestibular  nystagmus: 
1.  Turning.  Table  of  nystagmus  after  turning.  2.  Caloric.  Table  of 
nystagnuis  after  tlouching.  Law  of  vestibular  nystagnuis — the  eyes  are 
always  drawn  in  the  direction  of  the  endolympli  movement. 

XVI.  Vestibular  Vertigo 153 

Tracts  in  detail:  1.  P'rom  horizontal  canal  to  cerebral  cortex.  2.  From 
vertical  canals  to  cerebral  cortex.  Planes  of  Vestibular  Vertigo.  Hori- 
zontal plane  least  unpleasant;  bearing  of  this  on  seasickness.  Production 
of  vertigo  by  ear-stimulation:  1.  Turning.  Table  of  vertigo  after 
turning.  2.  Caloric.  Table  of  vertigo  after  douching.  Law  of  \'esti}nilar 
Vertigo — vertigo  is  always  in  a  direction  opposite  to  the  endolymph 
movement. 

XVII.  Pointing  Tests  of  Barany 165 

Orientation.  The  pointing  tests  have  proven  the  influence  of  the  ear 
over  all  portions  of  body-musculature.  Spontaneous  pointing  tests. 
Pointing  tests  after  ear-stimulation.  Past-pointing  after  turning.  Past- 
pointing  after  douching.  Explanation  of  past-pointing;  it  is  because  of 
the  vertigo  produced  by  ear-stimulation.  Tracts  for  i)ointing:  1.  The 
pyramidal  tract.  2.  The  cerebro-cerebello-spinal  tract.  Planes  of  past- 
pointing:  Table  of  past-pointing  after  turning.  Table  of  past-pointing 
after  ilouching.  Falling  may  be  regarded  as  a  past-j^ointing  of  the  entire 
body.  Table  of  falling  after  turning.  Table  of  falling  after  douching. 
Law  of  past-pointing  and  falling;  past-pointing  and  falling  are  always  in 
the  direction  of  endolymjih  movement. 

XVIII.  Technic    of   Examination   of   the   Auditory   Apparatus   and    of    the 

Ve.stihular  Apparatus 213 

Necessity  for  careful  technic.  Simplicity  and  accuracy  made  possible 
by  the  use  of  a  chart.  Description  of  the  chart.  The  functional  tests 
of  healing  of  B.  A.  Randall,  in  detail.  Examination  of  the  vestibular 
apparatus.  Spontaneous  phenomena.  Spontaneous  nystagmus.  Spon- 
taneous vertigo.  Spontaneous  falling.  Ear  stimulation.  Turning. 
Necessity  for  a  specially  constructed  chair  for  the  turning  tests.  De- 
scription of  the  American  modification  of  the  Barany  chair.  Nystagmus 
after  turning;  vertigo  after  turning;  jiointing  tests  after  turning;  falling 
tests  after  turning.  Technic  of  caloric  test  of  Barany.  Nystagmus, 
vertigo,  past-i)ointing  and  falling  after  douching.  Technic  of  electrical 
tests. 

XIX.  Examination  of  a  Case  With  the  Use  of  Chart. 249 

Concise  statement  of  routine  method  of  examining  a  patient;  a  chart 
filled  in  with  the  responses  to  V)e  found  in  a  normal  individual. 

XX.  Practical  Considerations 255 

The  significance  of  findings  in  nose,  mouth,  throat,  larynx  and  ear. 
Comparison  of  mechanism  and  values  of  the  turning  and  caloric  tests. 
Suggestions  in  guarding  against  making  the  tests  unpleasant  to  the 
patient.  Method  of  examining  bed-ridden  patients.  \'alue  of  making 
summaries  as  the  tests  proceed — drawing  conclusions  as  to  what  each 
test  indicates.  Simple  method  of  remembering  what  the  normal  responses 
should  be. 


CONTENTS  xi 

XXI.  Pathologic  Considerations 263 

Up  to  this  chapter  we  have  considered  only  the  normal  auditor}'  and 
vestibular  findings;  we  now  consider  the  abnormal.  Interpretation  of 
the  findings  in  the  auditory  mechanism;  catarrhal  deafness,  impairment 
of  the  cochlea,  destruction  of  the  cochlea.  Lesion  of  trapezoid  bodies 
might  jiroduce  complete  binaural  deafness.  "Word-deafness"  signifies 
lesion  in  posterior  portion  of  first  and  second  temporal  convolutions. 
Interpretation  of  findings  in  the  vestibular  mechanism.  Spontaneous 
nystagmus.  Spontaneous  vertical  nystagmus,  indicative  of  involvement 
of  brain-stem.  Spontaneous  vertigo.  Spontaneous  pointing.  Spon- 
taneous falling.  After  ear-stimulation:  Significance  of  absence  of 
nystagmus  after  stimulation;  the  absence  of  vertigo;  the  absence  of 
past-pointing;  the  absence  of  falling.  "  Perverted"  nystagmus,  "inverse" 
nystagmus;  either  indicative  of  involvement  of  brain-stem.  Conjugate 
deviation  instead  of  nystagmus  indicates  lesion  of  cerebro-ocular  tracts. 

XXII.  Hypothetical  Cases 269 

In  order  to  simplify  method  of  interpretation  it  is  helpful  to  state  in 
dogmatic  form  the  phenomena  to  be  expected  from  a  lesion  in  any  given 
location.    Hj'pothetical  cases  given  in  full  detail  with  use  of  charts. 

XXIII.  Pathologic  Cases  Analyzed 294 

In  order  that  the  findings  of  an  ear-examination  be  j^roperly  interpreted 
the  following  must  be  observed:  1.  The  technic  of  examination  must 
be  accurate  and  painstaking.  2.  The  data  must  be  recorded  on  a  suitable 
chart.  3.  One  must  be  able  to  visualize  the  pathways  constituting  the 
vestibular  apparatus.  The  best  method  for  determining  the  location  of 
intracranial  lesions  is  that  of  elimination.  A  certain  group  of  findings 
upon  ear-stimulation  is  usually  observed  in  certain  lesions,  and  these 
constitute  the  "phenomenon-complex"  for  that  lesion.  Eight  such 
"phenomena-complexes"  recognized.  In  order  to  make  clear  the  method 
of  analysis  the  cases  have  been  grouped  into  two  main  classifications — 
peripheral  and  central.  Presentation  of  cases  and  the  method  of  analysis 
in:  1.  Peripheral  lesions — circumscript  labyrinthitis  with  and  without 
fistula;  toxic  labyrinthitis  from  various  causes;  lesions  of  the  VIII  Nerve, 
both  traumatic  and  toxic.  2.  Central  lesions.  Lesions  of  medulla 
oblongata,  pons,  inferior  cerebellar  peduncle,  middle  cerebellar  peduncle, 
cerebelhun,  IV  ventricle,  ba.se  of  the  cerebral  crura,  parietal  lobe,  occipital 
lobe,  and  temporal  lobe.  Intracranial  complications  of  mastoiditis; 
cerebellar  abscess  and  tempero-sphenoidal  abscess.  Cerebello  pontile 
angle  tumors. 


ILLUSTRATIONS 


FIG.  PAGE 

Head  00°  Buck;  Head  ."30°  Forward;  Head  120°  Forward Frontispiece 

1.  Turning  to  tlie  liight,   Head  I'brward  30",  Stimulating  Both  Horizontal  [Semi- 

circular Canals 6 

2.  Method  of  Douching  the  Ear 7 

3.  Right  Internal  Ear,  V'iewed  from  Within 77 

4.  Head  Inclined  30°  Forward 78 

5.  Head  Inclined  120°  forward 79 

6.  Head  Inclined  60"  Backward 80 

7.  Scheme  of  the  Right  Horizontal  Canal 85 

8.  Current  Away  from  the  Ampulla  in  the  Right  Horizontal  Canal 85 

9.  Current  Toward  the  Ampulla  in  the  Right  Horizontal  Canal 86 

10.  The  Vertical  Semicircular  Canals  (Right) 86 

11.  Current  Away  from  the  Ampulla^ 87 

12.  Current  Toward  the  Ampulla^ 87 

13.  View  of  Right  Side  of  Spinal  Cord,  Medulla  Oblongata,  Pons  and  Cerebellum ....  92 

14.  Left  Side  of  Brain-Stem,  Viewed  from  Behind  and  Above 93 

15.  Brain- Stem  Viewed  from  in  P^ront  and  Below 94 

16.  Medulla  Oblongata   and   Pons   Viewed   from   Behind   and   Above,    showing   the 

Acoustic  Stria^  in  the  Floor  of  the  IV  Ventricle 96 

17.  Medulla  Oblongata,  Pons,  Cerebellar  Peduncles  and  Crura  Cerebri,  Viewed  from 

Behind  and  Above 97 

18.  Cerebellum  and  Brain-Stem  Viewed  from  Below 101 

19.  Posterior  View  of  Relation  of  Cerebrum  and  Cerebellum 102 

20.  Sagittal  Section  of  Brain,  Showing  F^ntire  Left  Half  of  Cerebrum,  Pons,  Medulla 

Oblongata  and  Cerebellum 103 

21.  Inferior  Aspect  of  Cerebrum,  Brain-Stem  and  Cerebellum 104 

22.  Cerebellum  Viewed  from  Below  and  in  Front 105 

23.  Superior  Aspect  of  Cerebellum 106 

24.  Cerebellum  Viewed  from  Below  and  in  Front 107 

25.  Cerebellum  and  Cerebral  Crura  Viewed  from  Above  and  Behind 108 

26.  Dissection  of  Structures  Through  Which  Impulses  Producing  Vertigo  Pass  to  the 

Posterior  Portion  of  First  and  Second  Temporal  Convolutions 109 

27.  Dissection  of  Structures  Through  Which  Impulses  Producing  Vertigo  Pass  to  the 

Posterior  Portion  of  First  and  Second  Temporal  Convolutions 110 

28.  Dissection  of  Structiues  Through  Which  Impulses  Producing  Vertigo  Pass  to  the 

Temporal  Lobe Ill 

29.  Dissection  of  Structures  Through  which  Impulses  Producing  Vertigo  Pass  to  the 

Temporal  Lobe 112 

30.  Cerebellar  Localization;  Zones  and  Centres  of  the  Superior  Surface  of  the  Cerebellum  116 
31'.  Cerebellar  Localization;  Zones  and  Centres  of  the  Inferior  Surface  of  the  Cerebellum   1 16 

32.  Pathways  of  Fibres  from  Cochlea,  Horizontal  Canal  and  Vertical  Canals 128 

33.  Consecutive  Series  of  Diagrams;  Pathways  of  Fibres  from  the  Right  Horizontal 

Canal 130 

34.  Continuation  of  Consecutive  Series  of  Diagrams,  Pathways  of  Fibres  from  the 

Right  Horizontal  Canal 131 

35.  Consecutive  Series  of  Diagrams;  Pathways  of  Fibres  from  the  Right  Vertical 

Canals 133 

36.  Continuation  of  Consecutive  Series  of  Diagrams;  Pathways  of  Fibres  from  the 

Right  Vertical  Canals 134 

37.  Diagram  of  Cross-Section  of  Different  Levels  of  the  Brain-Stem 135 

38.  Horizontal  Nystagmus 137 

39.  Vestibulo-Ocular  Tract  of  Horizontal  Canal  Fibres 139 

40.  Vestibulo-Ocular  Tract  of  Horizontal  Canal  Fibres 141 

41.  Eyes  Drawn  in  Direction  of  Endolymph  Movement 142 

42.  Eyes  Drawn  in  Direction  of  Endolymph  Movement 143 

43.  Cerebral  Fibres  to  Eye-Muscle  Nuclei 146 

44a,  446,  45.  Methods  of  Producing  Vestibular  Nystagmus 148 

xiii 


xiv  ILLUSTRATIONS 

40.  \'estibulo-Ceiebel!o-CV'iebnil  Tiaet  for  Horizontal  Canal  Fibres  (Producing  Vertigo) 

Current  away  i'roni  Ami)ulte 15-4 

47.  Vestibule- Cerebello-Cercbrai    Tract    for    Horizontal    Canal    Fibres    (Producing 

Vertigo ) 155 

48.  \'estibulo-Cerebello  Tract  for  \'ertical  Canals  Fibres 15U 

49.  Vestibulo-Cerebello-Cerebral  Tract  for  Vertical  Canals  Fibres  (Producing  \'ertigo)  157 

50.  Turning  to  the  Left  with  the  Head  60°  Back 160 

51.  Shoulder  from  Above 167 

52.  Shoulder  from  Above 168 

53.  Shoulder  from  Below 169 

54.  Shoulder  from  the  Side 171 

55.  Shoulder  to  the  Side 172 

56.  Elbow  from    Below 173 

57.  Elbow  from  Above 174 

58.  Wrist  from  Below 176 

59.  Hip  from  Below 176 

60.  Neck  from  Below 178 

61.  Trunk  from  Below 179 

62.  After  Turning  to  Right,   Head  30°  Forward,  Endolymph  Movement  in  Horizontal 

Canal  is  to  the  Right;  Therefore  Patient  Past-points  to   Right 180 

63.  After  Turning  to  Left,  Patient  Past-points  to  Left 182 

64.  After  Douching  Right  Ear,  Water  68°,  Head  30°  Forward,  Stimulating    \'ertical 

Canals,  the  Endolymph  Movement  is  Down  to  the  Right;  Therefore  Patient 

Past- points  to  Right 183 

65.  After  Douching  Right  Ear,  Water  68°,  Head  60°  Back,  Endolymph    Movement 

is  Horizontal  Canal  is  Down  to  the  Right,  Therefore   Patient   Past-points  to 

Right 184 

66.  After  Douching  Left  Ear,  Water  68°,  the  Endol,ymph   Movement  is  Down  to  the 

Left;  Therefore  Patient  Past-points  to  the  Left 185 

67.  After  Douching  Left  Ear,  Head  60°  Back,  Endolymph   Movement  in  Left  Hori- 

zontal Canal  is  to  Left ;  Therefore  Patient  Past-points  to  I^eft 186 

68.  Turning  to  the  Right,  Head  Back  60° 190 

69.  Produces  Past-pointing  to  the  Right 191 

70.  Turning  to  the  Left,  Head  60°  Back,  Causes  Endolymph  Movement  to  the  Left.  .  192 

71.  Therefore  Patient  Past-points  to  the  Left 193 

72.  Pyramidal  Tract  Becoming  the  Crossed  Pyramidal   Tract   194 

73.  Cerebro-(!erebello-Spinal  Tract 195 

74.  Pointing  Tracts 196 

75.  Pointing  Tracts 197 

76.  Turning  to  Left  with  Head  Inclined  Toward  Right  Shoulder  Causes  Endolymph 

Movement  Downward  in  Sagittal  Plane 200 

77.  Therefore  Patient  Past- points  Below ' 201 

78.  Turning  to  Right,  Head   120°  Forward,  Causes  Endolymph    Movement  to  the 

Right  in  the  Frontal  Plane 204 

79.  Therefore  on  Sitting  Up,  Patient  Falls  to  the  Right  in  the  Frontal  Plane 205 

80.  Turning  to  Right  With  Head  60°  Back 206 

81.  Will  Produce  Falling  to  Left  When  Head  is  Raised  to  Upright  Position 207 

82.  Turning  to  Left,  Head  120°  Forward,  Causes  Endolymph  Movement  to  the  Left 

in  the  Frontal  Plane 208 

83.  Therefore  on  Sitting  Up,  Patient  Falls  to  the  Left  in  the  Frontal   Plane 209 

84.  Turning  to  Left,   Head   Inclined   Toward   Right  Shoulder,   Causes    Endolymph 

Movement  Downward  in  Sagittal  Plane 211 

85.  Baranv's  Pelvic  Girdle  Test  226 

86.  Baranv's  Pelvic  f  Jirdle  Test 227 

87.  Baranv's  Pelvic  Curdle  Test 228 

88.  BaranV's  Pelvic  Cirdle  Test 229 

89.  Goniometer 230 

90.  Goniometer 231 

91.  Goniometer 232 

92.  Original  Barany  Chair 234 

93.  Latest  Modification  of  American  Barany  Chair 235 

94.  Turning  to  the  Right,  Head  30°  Forward,  Stimulating  Both  Horizontal  Canals.  .  238 


ILLUSTRATIONS  xv 

95.  Turning  to  Kight,  Head  120°  Forward,  Stimulating  Vertical  Canals  of  Both  Ears  239 

96.  Turning  to  Right,  Head  60°  Back,  Stimulating  the  Vertical  Canals  of  Both  Ears.  240 

97.  Dotted  Lines  Indicate  Lesion 297 

98.  Arrow  Points  to  Lesion 298 

99.  Arrow  Points  to  Lesion 299 

100.  Arrow  Points  to  Lesion 300 

101.  Arrow  Points  to  Lesion 301 

102.  Arrow  Points  to  Lesion 302 

103.  Arrow  Point.s  to  Lesion 303 

104.  Arrow  Points  to  Lesion 304 

105.  Ariow  Points  to  Lesion 305 

106.  Pointing;  Right  Shoulder  from  Above 307 

107.  Pointing;  Left  Shoulder  from  Above 307 

108.  Pointing;  Elbow  from  Above 307 

109.  Pointing;  Right  Hip  from  Below 307 

110.  Pointing;  Left  Hip  from  Below 307 

111.  Location  of  the  Lesion  Indicated  by  Dotted  Lines 314 

112.  Location  of  the  Lesion  Indicated  by  Dotted  Lines 318 

113.  Location  of  Lesion  Indicated  by  Dotted  Lines 322 

114.  Location  of  Lesion  Indicated  by  Dotted  Lines 332 

115.  Location  of  Lesion  Indicated  by  Dotted  Lines 344 

116.  Ghoma  of  the  Pons '. 345 

117.  Location  of  Le-sion  Indicated  by  Dotted  Line 351 

118.  Cerebellar  Cortex  Uninvolved 380 

119.  Cerebellar  Cortex  Intact 381 

120.  Cerebellar  Cortex  Intact.    Cyst  Involving  Vermis 382 

121.  Absc&ss,  Sub-Cortical.  Right  Parietal  Region 383 

122.  Tumor  of  Corpus  Callosum 398 

123.  Tumor  of  Corpus  Callosum 399 

124.  Tumor  of  the  Left  Cerebello-Pontile  Angle  Attached  to  Pons 406 

125.  Brain  Showing  Tumor  of  the  Left  Cerebellar  Lobe  and  Involving  the  Cerebello- 

Pontile  Angle 410 

126.  Same  Specimen  as  Figure  125,  Showing  Only  Cerebellum  and  Brain- Stem  which 

have  been  Separated  from  Cerebrum 411 

127.  Large  Tumor  in  Right  Cerebello-Pontile  Angle 417 

128.  Tumor  in  Right  Cerebello-Pontile  Angle 422 

129.  Large  Cyst  in  Right  Cerebello  Pontile  Angle ., 429 


PART  I 

THE  PRACTICAL  USES  OF  A  STUDY  OF  THE 
INTERNAL  EAR 


EQUILIBRIUM  AND   VERTIGO 

CHAPTP]R  I 
NEURO-OTOLOGY 

A^Y  work  in  physiology"  may  be  looked  on  as  an  interesting 
study,  but  from  the  standpoint  of  most  of  us  in  the  practice  of 
medicine,  any  research  work  attains  a  much  more  real  importance 
when  it  can  be  directly  applied  to  clinical  woik  and  proves  to  have 
an  immediate,  practical  usefulness.  AVhen  we  consider  the  inti- 
mate relation  of  the  ear  to  the  rest  of  the  body  through  the  ner- 
vous system,  it  at  once  becomes  evident  that  a  wealth  of  infor- 
mation may  be  obtained  from  such  a  study.  Neuro-otology  is  a 
suitable  name  for  this  study,  in  that  it  consists  of  an  analysis  of 
the  internal  ear  and  its  associated  intracranial  nerve-pathways. 
Although  it  is  obviously  an  otologic  study,  and  is  useful  in  the 
analysis  of  ear-conditions,  yet  it  has  a  much  broader  significance 
in  its  usefulness  as  a  means  of  providing  data  in  general  medical 
and  surgical  diagnosis  and  treatment.  It  not  only  opens  up  a  new 
field  for  investigation  in  physiology,  therefore,  but  furnishes  in- 
formation of  diagnostic  value  in  the  every-day  examination  of 
patients. 

The  value  of  the  information  gathered  from  the  study  of  the 
eye  and  nerve-pathways  from  the  eye  is  universally  conceded, 
but  it  is  only  in  the  past  few  years  that  similar  possibilities  in  ear- 
study  have  come  to  light.  The  eye-specialist  not  only  relieves  ills 
strictly  confined  to  the  ocular  tissues  themselves — conjunctivitis, 
refractive  errors,  muscle-imbalance  and  cataract — but  he  is  asked 
bj''  men  in  other  fields  of  medical  and  surgical  Avork  for  valuable 
information  concerning  intracranial  conditions,  renal  and  vascular 
disease,  metabolic  disturbances,  varied  evidences  of  intoxications, 
and  is  also  asked  to  interpret  their  significance  in  regard  to  the 
general  health  of  the  patient.    Asa  result  of  this  sort  of  service, 


4  EQUILIBRIUM  AND  VERTIGO 

oijlitlialmology  has  for  years  taken  its  proper  place  in  general 
medicine.  Otology  is  now  entering  into  a  similar  field  of  useful- 
ness. The  value  of  ear-study,  however,  is  not  3"et  generally  recog- 
nized. The  internist  does  not  turn  to  the  otologist  for  the  analysis 
of  the  cause  of  vertigo.  The  syphilologist  does  not  yet  recognize  the 
uses  of  ear-tests  in  detecting  early  involvement  of  the  central  ner- 
vous system.  The  neurologist  does  not  yet  catalog  among  his  indis- 
pensables  the  accurate  data  otology  can  furnish  concerning  the 
degree  of  function  of  the  VIII  Nerve,  in  a  differentiation  between 
labyrinth  and  intracranial  lesions  and  in  intracranial  localization. 
The  general  surgeon  does  not  recognize  that  a  lesion  within  the 
internal  ear  may  simulate  intra-abdominal  carcinoma,  nor  does 
the  cranial  surgeon  yet  recognize  the  value  of  ear-examination 
in  helping  him  to  diagnosticate  and  locate  intracranial  lesions. 

This  newer  usefulness  of  otology  is  made  possible  by  a  study 
of  the  vestibular  or  ''balance"  portion  of  the  ear.  The  internal 
ear  has  long  been  thought  of  merely  as  the  organ  of  hearing;  viewed 
in  this  light  its  affections  were  mainly  of  local  significance.  Be- 
cause of  its  supposedly  limited  connections  with  the  nervous  sys- 
tem, its  phenomena  were  seldom  regarded  as  the  expression  of 
any  general  disorder.  Now,  however,  it  is  recognized  that  the 
internal  ear  consists  of  two  organs  instead  of  one — the  cochlea, 
which  is  the  organ  of  hearing,  and  the  kinetic-static  labyrinth, 
which  is  the  organ  of  equilibration.  It  is  this  kinetic-static  portion 
of  the  ear,  consisting  of  the  utricle,  saccule  and  the  three  semi- 
circular canals,  that  has  been  through  all  the  years  a  "terra  incog- 
nita." It  is  only  in  the  past  few  years  that  the  function  of  the 
vestibular  portion  of  the  labyrinth  has  been  carefully  studied, 
pre-eminentlj^  by  the  Vienna  group  of  otologists,  to  whom  we  are 
indebted  for  the  new  methods  of  testing  the  internal  ear.  Robert 
Barany  received  the  Nobel  prize  in  1915  for  this  work,  and  he 
is  to  be  regarded  as  the  pioneer  in  the  clinical  application  of  the 
study  of  the  relations  of  the  ear  and  the  central  nervous  system. 
The  internal  ear  as  the  chief  organ  of  balance' or  equilibration  at 
once  assumes  an  importance  far  greater  than  the  ear  as  an  organ 
of  hearing.    As  an  equilibratory  organ  it  must  be  richly  supplied 


NEURO-OTOLOGY  5 

with  nerve-pathways  connecting  it  intimately  Avith  many  nerve- 
centres  which  in  their  ultimate  distribution  alfect  the  entire  body. 
It  is  this  larger  mechanism  that  has  opened  up  new  possibilities 
for  the  clinician.  The  new  ear-tests  stimulate  not  only  the  ear 
itself  but  this  entire  widely  distributed  nerve  apparatus.  A  stimu- 
lus applied  to  the  ear  produces  phenomena  very  remote  from  the 
ear  itself;  parts  of  the  body  even  as  remote  as  the  foot  may  be 
affected  by  such  stimulation.  There  is  in  fact  no  portion  of  the 
body-musculature  that  is  unaffected  by  stimulation  of  the  ves- 
tibular labyrinth.  It  is  evident  that  all  these  parts  of  the  body 
can  be  affected  only  because  of  nerve-pathways  connecting  them 
with  the  ear.  When  stimulation  of  the  ear  produces  the  expected 
normal  phenomena  it  demonstrates  that  these  particular  path- 
ways are  intact ;  conversely,  an  absence  of  normal  responses  indi- 
cates an  impairment  by  disease  of  the  ends  or  lines  of  these 
pathways. 

The  ear-tests  consist  of  stimulating  the  semicircular  canals; 
this  is  done  by  revolving  a  person  in  a  turning-chair  (Fig.  1),  or 
by  douching  the  ears  with  either  cold  or  hot  water  (Fig.  2),  or  by 
applying  the  galvanic  current  to  the  ear.  Such  ear-stimulation 
produces  certain  definite  phenomena — a  rhythmic  jerking  of  the 
eyes  known  as  nystagmus,  and  a  subjective  sensation  of  turning 
which  may  be  termed  a  systematized  vertigo.  The  two  distinct 
phenomena  then  are  nystagmus  and  vertigo.  Because  of  this 
vertigo,  a  patient  falls  in  a  definite  direction,  and  also  when,  blind- 
folded, he  attempts  to  find  with  his  finger  or  his  foot  an  object  he 
has  previously  touched,  he  is  unable  to  find  it  but  ''past-points"  to 
the  right  or  left,  above  or  below,  depending  on  the  direction  of 
the  vertigo.  These  various  phenomena  are  invariably  present  in 
normal  people,  and  furthermore  always  follow  definite  laws.  For 
example,  turning  the  patient  to  the  right  with  the  head  in  the 
upright  position,  stimulating  both  "horizontal"  semicircular 
canals,  produces  a  horizontal  nystagmus  to  the  left,  a  subjective 
sensation  of  turning  to  the  left,  and  a  "past-pointing"  to  the 
right.  Douching  the  right  ear  with  cold  water,  head  upright, 
stimulating  the  vertical  canals,  produces  a  rotary  nystagmus  to  the 


■imBim. 


f^; 


Fig.  1. — Turniiift  to  the  right,  head  forward  :iO°,  stimulating  both  horizontal  semicircular  canals. 


np:uro-otology 


Fig.  2. — Method  of  douching  the  ear.      Water  is  allowed  to  flow  gently  against  the  drum- 
membrane,  from  a  receptacle  2  to  3  feet  above  the  patient's  head. 


8  EQUILIBRIUM  AND  VERTIGO 

left,  a  sensation  of  falling  to  the  left,  ''past-pointing"  to  the  right 
and  actual  falling  to  the  right.  Hot  water  produces  exactly  the 
opposite  phenomena.  This  then,  in  brief,  is  the  method  of  testing 
this  vestibular  apparatus  or  ''Balance  Mechanism." 

The  fundamental  principles  underlying  these  phenomena  are 
very  simple  and  may  be  expressed  as  follows:  When  "Father 
Adam"  first  turned  to  the  right,  to  speak  figuratively,  the  fluid 
(called  "endolymph")  in  his  semicircular  canals  lagged  behind — 
relatively  moved  to  the  left.  His  sight  and  muscle-sense  informed 
him  that  he  was  turning  to  the  right;  consequently  he  came  to 
interpret  endolymph-movement  to  the  left  to  signify  that  he  was 
turning  to  the  right.  He  always  turned  away  from  the  endolymph, 
and  for  this  reason  he  recognized  endolymph  movement  in  one 
direction  to  signify  that  he  was  moving  in  the  opposite  direction. 
Each  child  born  of  Adam  passes  through  the  same  experience — 
he  learns  to  interpret  impulses  from  the  labyrinth  just  as  he 
comes  to  interpret  stimuli  received  from  the  retina.  Images  on 
the  retina  are  upside  down,  but  in  the  course  of  time  the  child 
learns  to  reverse  this  image  in  his  consciousness  and  to  realize 
that  the  external  object  is  really  right  side  up.  Similarly  through 
countless  repetitions  he  comes  to  recognize  that  endolymph  move- 
ment in  one  direction  means  that  he  is  moving  in  the  opposite 
direction. 

When  an  individual  moves  past  external  objects,  his  eyes 
attempt  to  fix  upon  certain  objects  as  they  pass.  He  does  this 
in  the  attempt  to  stabilize  the  sensorium.  When  traveling  in  a  rail- 
road train  his  eyes  fix  upon  telegraph  poles  and  other  objects  as 
they  pass — consequently  his  eyes  move  in  the  direction  of  the  pass- 
ing object.  Similarly,  when  he  is  turning  to  the  right,  his  eyes, 
although  closed,  have  been  trained  to  move  to  the  left  in  the  direc- 
tion of  the  external  objects  which  are  moving  to  the  left. 

Experimental  stimulation  of  the  ear,  by  turning  in  a  revolving- 
chair  or  by  douching  with  cold  or  hot  water,  produces  an  artificial 
movement  of  the  endolymph.  After  an  individual  is  turned  to 
the  right  a  sufficient  number  of  times  to  cause  the  endolymph  to 
-catch  up  with  the  movement  of  the  body,  he  feels  that  he  is  standing 


NEURO-OTOLOGY  9 

still,  whereas  he  is  actually  turning  to  the  right.  As  there  is  no 
movement  of  the  endolymph  in  relation  to  the  hair-cells  within 
the  ear,  his  interpretation  is  that  he  himself  is  not  moving.  Now 
if  the  chair  be  stopped,  the  endolymph  by  its  momentum  continues 
to  move  to  the  right;  he  therefore  feels  that  he  is  rotating  to  the 
left,  although  he  is  actually  sitting  still.  If  the  right  ear  be  douched 
with  cold  water,  the  chilled  endolymph  moves  downward  to  the 
right  and  the  individual  feels  that  he  is  falling  to  the  left.  Under 
all  circumstances  endolymph  movement  in  one  direction  means  to 
the  individual  that  he  is  moving  in  the  opposite  direction;  the  eyes 
are  always  drawn  in  the  direction  of  the  seemingly  passing  object. 
This  is  the  mechanism  of  the  vertigo  and  the  eye-movement  caused 
by  stimulation  of  the  semicircular  canals. 

In  the  following  chapters  of  Part  I  will  be  shown  how  the 
study  of  the  balance  apparatus,  as  just  outlined,  is  raised  out  of 
the  field  of  merely  physiologic  interest  and  how  it  serves  a  definite 
purpose  in  the  '*  healing  of  the  sick. ' '  It  must  be  remembered  above 
all  that  the  work  of  otologists  along  the  lines  of  the  relation  of 
the  ear  to  the  general  system  is  only  in  its  infancy,  and  in  the 
following  chapters  we  will  attempt  to  give  a  hint  of  the  future 
possibilities  of  this  study  as  well  as  to  indicate  how  the  co-opera- 
tion of  otologists  with  those  in  other  branches  of  medical  work 
is  already  of  use  in  general  medical  and  surgical  diagnosis. 


CHAPTER  II 

THE  EAR  AND  THE   GENERAL   PRACTITIONER 

Equilibkation.     The  Study  of  \'ertigo 

The  fact  of  paramount  importance  in  the  study  of  neuro- 
otology  is  that  the  ear  is  the  most  important  organ  in  the  main- 
tenance of  equilihration.  Equilibration  in  general  depends  upon 
impulses  from  three  sources — the  kinetic-static  sense,  the  sight  and 
the  muscle-sense.  For  centuries  man  has  been  credited  with  only 
five  special  senses.  Within  the  last  two  decades  the  sixth  sense, 
'' Muscle,  joint  and  splanchnic  sense,"  came  to  be  recognized.  It 
is  unlike  the  other  senses  in  that  it  does  not  make  its  impression 
upon  our  consciousness.  By  means  of  this  sixth  sense  the  indi- 
vidual performs  co-ordinate  acts  automatically  and  unconsciously. 
The  recent  studies  of  the  internal  ear  show  that  the  equilibratory 
portion  of  the  ear  constitutes  a  seventh  sense,  which  may  be  termed 
the  ''kinetic-static  sense."  The  kinetic-static  function  of  the  laby- 
rinth is  a  separate  sense  just  as  truly  as  the  sense  of  hearing  or 
the  sense  of  sight.  Any  special  sense  depends  upon  an  end-organ 
for  the  reception  of  stimuli,  nerves  to  convey  these  stimuli,  and  a 
nerve-centre  to  interpret  their  significance.  The  kinetic-static 
sense  fulfils  these  requirements,  as  it  is  constructed  on  this  plan, 
in  that  it  consists  of  an  end-organ,  the  semicircular  canals  and 
the  vestibule,  for  receiving  stimuli,  a  conducting  nerve,  the  VIII 
Xerve,  and  definite  tracts  leading  to  brain-centres  where  the  signifi- 
cance of  the  stimuli  is  interpreted  in  the  form  of  equilibration, 
or  that  disturbance  of  equilibration  wliicli  is  known  as  vertigo. 

It  is  therefore  best  to  consider  that  there  are  seven  special 
senses:  (1)  sight,  (2)  hearing,  (3)  taste,  (4)  smell,  (5)  touch,  (6) 
muscle-sense,  (7)  kinetic-static  sense. 

Perfect  equilibration  is  accomplished  through  an  harmonious 
co-operation  of  the  first,  the  sixth  and  the  seventh  senses — the 
eye,  the  muscle-sense  and  most  particularly  the  kinetic-static  sense. 

10 


THE  EAR  AND  THE  GENERAL  PRACTITIONER    11 

This  "sense  trilogy"  makes  possible  estimations  of  all  sorts, 
orientation,  locomotion,  estimation  of  the  rate  of  motion,  esti- 
mation of  weight,  and  realization  of  posture  and  position.  Of 
the  "trilogy,"  the  kinetic-static  sense  is  of  i)e(niliar  importance, 
in  that  its  "end-organ,"  the  kinetic-static  labyrinth,  has  for  its 
sole  function  the  maintenance  of  balance. 

After  impairment  or  loss  of  one  of  the  senses  responsible  for 
equilibration,  compensation  may  take  place,  to  a  certain  extent. 
The  tabetic  may  be  taught  to  avail  himself  of  his  visual  sense  and 
of  his  static  sense  in  co-ordinating  his  movements.  Similarly, 
the  blind  man  is  able  to  stand  or  walk,  until  deprived  of  the  guid- 
ance of  either  the  muscle-sense  or  the  kinetic-static  sense.  Deaf 
mutes,  in  whom  the  kinetic-static  sense  is  destroyed,  are  enabled  to 
maintain  their  balance  by  means  of  the  sight  and  muscle-sense,  and 
develop  inco-ordination  only  in  the  dark  or  in  the  water.  Full 
compensation,  however,  cannot  take  place  unless  two  of  these 
three  senses  remain  unimpaired,  and  perversion  of  any  one  of  them 
may  be  much  more  disturbing  than  its  loss. 

The  realization  that  the  ear  is  the  organ  of  balance  throws 
an  entirely  new  light  on  the  importance  of  this  organ  to  the  general 
practitioner.  Previous  to  this  conception  of  the  ear  as  the  essen- 
tial organ  of  equilibration,  the  physician  has  regarded  the  ear 
somewhat  as  follows :  if  the  patient  is  deaf  a  specialist  should  see 
what  he  can  do  to  improve  the  hearing  and  if  there  is  any  inflam- 
mation of  the  ear  it  should  receive  local  attention.  Far  more 
important  and  yet  far  less  recognized  and  appreciated  is  the  part 
that  the  equilibratory  portion  of  the  internal  ear  plays  in  the  well- 
being  of  the  entire  body.  A  knowledge  of  this  subject  is  neces- 
sary to  the  general  practitioner  because  of 

1.  The  value  of  the  new  ear-tests  in  determininrf  the  cause  of 
vertigo,  no  matter  what  its  type  or  origin;  it  is  with  such  "dizzy 
cases"  that  the  physician  comes  in  daily  contact;  and 

2.  The  necessity  in  his  daily  practice  of  recognizing  pathologic 
conditions  of  the  internal  ear  itself;  such  conditions  are  being 
continually  overlooked  at  the  present  time  because  of  a  lack  of 
familiarity  with  this  new  subject. 


12  EQUILIBRIUM  AND  VERTIGO 

Vertigo 

Although  it  has  been  generally  recognized  for  many  years 
that  vertigo  may  result  from  ear  disturbances,  the  conception  that 
all  vertigo,  from  whatsoever  cause,  is  peculiarly  an  ear  study,  is 
the  outcome  of  the  study  of  neuro-otology.  The  general  prac- 
titioner is  constantly  confronted  with  cases  of  ''dizziness,"  and 
yet  it  is  surely  not  overstating  the  fact  to  say  that  at  best  he 
can  only  g-uess  at  its  clinical  significance.  Those  suffering  from  it 
are  at  times  so  desperate  that  they  would  be  willing  to  go  to  any 
length  in  order  to  obtain  relief.  The  stability  of  the  earth  is  one 
of  the  most  fundamental  facts  of  our  experience — one  of  our  essen- 
tial concepts ;  it  is  no  wonder  that  the  ancients  found  it  hard  to 
believe  that  the  earth  moved.  Therefore,  if  an  earthquake  shakes 
the  very  ground  under  his  feet,  man  is  astounded  and  feels  that 
even  the  foundations  of  his  reason  and  his  hope  for  the  future 
are  being  snatched  away.  The  motion  of  the  sea  with  its  uncer- 
tainties and  nauseating  disturbances  only  occasionally  is  so  over- 
whelming as  to  obliterate  the  assurance  that  this  is  but  temporary 
and  will  be  looked  back  upon  with  half-contemptuous  self-confi- 
dence just  as  soon  as  one  regains  "terra  firma."  The  sufferer 
from  dizziness,  however,  has  no  such  reassurance.  "To  him  who 
wears  shoes  the  whole  world  is  covered  with  leather,"  and  "He 
that  is  giddy  thinks  the  world  turns  round."  The  dizzy  man  car- 
ries the  terror  of  earthquake  wherever  he  goes,  feeling  that  for 
him  all  order  of  the  universe  is  at  an  end ;  he  is  disabled  for  to-day 
and  disheartened  for  the  future.  The  inebriate  suffers  his  loss 
of  equilibrium  and  co-ordination  under  an  exhilaration  that  robs 
it  of  its  message  to  his  benumbed  brain ;  he  is  impressed  with  the 
seeming  incongruity  rather  than  with  his  own  impotence.  Xornial 
equilibrium  is  essential  not  only  for  the  worker  but  even  to  the  idler 
if  he  is  to  live  in  comfort  and  safety. 

Unfortunately  in  the  past  the  physician  could  offer  but  little 
in  the  Avay  of  help.  He  has  been  accustomed  to  regard  vertigo 
as  something  vagTie  and  mysterious  and  quite  beyond  the  reach  of 
medical  aid,  with  the  result  that  there  is  hardly  anj^  subject  in 


THE  EAR  AND  THE  GENERAL  PRACTITIONER   13 

the  Avliole  domain  of  medicine  more  chaotic  than  that  of  vertigo. 
Doctors  repeatedly  speak  in  a  general  and  indefinite  way  of  **  intes- 
tinal" or  "stomach"  vertigo,  dizzy  spells  from  refractive  errors, 
from  Bright 's  disease,  indigestion  or  neurasthenia,  without  think- 
ing even  for  a  moment  of  the  real  mechanism  of  its  production. 
Above  all,  it  has  been  impossible  to  know,  in  any  given  case, 
whether  the  vertigo  was  due  to  a  functional  or  organic  cause  and 
still  less  to  recognize  whether  the  dizziness  was  of  trivial  signifi- 
cance or  whether  it  was  the  forerunner  of  some  grave  affection. 

In  the  light  of  the  new  ear-tests,  vertigo  should  be  regarded 
as  a  distinct  clinical  entit}^  deserving  just  as  careful  investigation 
and  analysis  as  fever  or  any  other  distressing  symptom.  By  ver- 
tigo is  meant  a  subjective  sensation  of  a  disturbed  relationshii^  of 
one's  own  body  to  surrounding  objects  in  space.  It  is  not  some 
general  manifestation  accompanying  disorders  of  this,  that  or  the 
other  organ,  but  it  is  a  disturbance  perceived  within  a  definite  part 
of  the  brain,  just  as  sight  and  hearing  are  perceived  within  the 
brain.  Therefore,  one  should  never  speak  of  gastric  vertigo, 
kidney  vertigo,  cardiovascular  vertigo,  idiopathic  vertigo,  or  any 
other  generalization  which  in  its  ultimate  analysis  means  nothing. 
The  stomach  of  itself,  or  the  kidneys,  or  the  heart,  can  no  more 
produce  vertigo  than  they  can  produce  sensations  of  flashes  of 
light,  hallucinations  of  sound,  or  obsessions  of  smell.  It  is  gener- 
ally known  and  admitted  as  a  matter  of  course,  that  the  light, 
sound  and  smell-sensations  in  these  instances  are  produced  by 
irritation  or  stimulation  within  the  brain  of  the  visual,  auditory  or 
olfactory  apparatus,  as  the  case  may  be.  All  conscious  sensations 
are  cerebral.  Headache,  be  it  due  to  constipation,  displacement 
of  pelvic  organs,  or  a  gastro-intestinal  disturbance,  is  nevertheless 
in  the  head.  In  just  the  same  way,  if  a  disturbance  in  any  organ 
of  the  body  is  accompanied  by  vertigo,  it  is  due  to  a  direct  attack 
on  the  apparatus  capable  of  producing  vertigo — namely,  the  inter- 
nal ear  or  its  intracranial  distribution. 

It  must  not  be  considered  that  vertigo  can  be  caused  only  by 
a  disturbance  within  the  ear  itself,  for  it  is  well  known  that  various 
visual  disturbances,  cardiovascular  affections,  gastric  or  alinien- 


14  EQUILIBRIUM  AND  VERTIGO 

tary  disorders  also  manifest  vertigo  as  a  symptom.  The  essential 
feature  is  that  it  is  a  direct  action  on  the  internal  ears  or  tlieir 
associated  pathways  in  the  brain,  that  is  responsible  for  the 
vertigo.  If  the  same  pathologic  cause,  for  one  reason  or  another, 
fails  to  irritate  the  ear  or  its  nerve-distribution,  there  icill  he  no 
vertigo.  The  internal  ears  and  the  intracranial  pathways  con- 
stitute the  apparatus  that  keeps  us  from  *' being  dizzy,"  The 
vestibular  mechanism  accomplishes  this  by  keeping  the  cerebrum 
continuously  informed  of  our  position  in  space  and  our  relation 
to  objects  around  us.  In  the  presence,  however,  of  some  pathologic 
condition  in  the  labyrinth  or  along  any  of  its  paths,  a  performance 
of  this  function  is  no  longer  possible;  objects  around  us  do  not 
appear  as  they  should ;  they  either  move  or  dance  before  us.  Our 
own  bodies  no  longer  feel  stable  upon  the  ground — in  other  words, 
we  are  diszi/  or  experience  sensations  of  vertigo  which,  if  severe 
enough,  result  in  our  inability  to  move  about  or  stand  upright. 

Viewed  in  this  light  manj^  conditions  in  the  category  of  the 
physician's  daily  experience — such  as  the  symptoms  of  a  "bilious 
attack" — attain  a  new  significance.  The  mere  ingestion  of  alco- 
holic beverages  does  not  produce  vertigo;  it  is  only  when  the 
alcohol  reaches  the  vestibular  apparatus  through  the  blood-stream 
that  dizziness  is  produced.  In  consideration  of  these  facts,  to 
speak  of  the  role  that  the  ear  and  its  ultimate  tracts  play  in  the 
production  of  vertigo,  is  like  speaking  of  the  role  the  heart  plays 
in  the  production  of  cardiac  murmurs.  Therefore,  just  as  we 
examine  the  heart  and  blood-pressure  to  determine  the  condition 
of  the  cardiovascular  system,  or  as  we  test  the  urine  in  suspected 
cases  of  nephritis  or  diabetes,  or  as  we  have  a  Wassermann  test 
made  in  cases  suspected  of  syphilis,  just  so  the  ear-tests  enable  us 
to  analyze  the  apparatus  responsible  for  dizziness.  Instead  of 
guessing,  w^e  can  then  know  the  reason  for  the  vertigo.  We  do 
not  hesitate  to  say  that  it  is  very  rare  that  a  ''dizzy"  case  remains 
obscure  after  these  ear-tests  and  in  most  instances  the  diagnosis 
becomes  clear  and  simple. 

Vertigo  is,  therefore,  essentially  an  ^^r-study.  Have  we  in  fact 
any  other  method  of  attacking  this  problem  except  by  the  ear-tests? 


-   THE  EAR  AND  THE  GENERAL  PRACriTIONER   15 

Surely  any  opinion  based  on  history  or  analogy  or  empiricism  is 
at  best  merely  a  conjecture. 

We  will  attempt  a  classification  of  all  possible  causes  of  vertigo 
and  then  present  actual  cases  of  the  various  types,  showing  how 
the  ear-tests  have  demonstrated  the  reason  for  the  vertigo.  If 
for  any  cause,  immediate  or  remote,  there  occurs  disturbance  of 
the  ear-mechanism,  there  is  a  resulting  vertigo.  Vertigo  may 
be  caused  by 

1.  Involvement  of  the  ear-mechanism  by  a  lesion  in  the  ear 
itself; 

2.  Involvement  of  the  ear-mechanism  by  a  lesion  affecting  the 
intracranial  pathways  from  the  ear; 

3.  Involvement  of  the  ear-mechanism  by  ocular  disturbance, 
either  through  the  eye-muscle  nuclei  or  through  association  fibres 
from  the  cuneus  to  the  cortical  terminus  of  the  fibres  from  the  ear 
in  the  posterior  portion  of  the  first  temporal  convolution; 

4.  Involvement  of  the  ear-mechanism  by  cardiovascular  dis- 
turbance; and 

5.  Involvement  of  the  ear-mechanism  by  toxaemias  from  any 
organ  or  part  of  the  body. 

So  far  as  we  have  been  able  to  determine,  this  classification 
includes  all  the  causes  of  vertigo ;  it  is  to  be  noticed  that,  regardless 
of  the  cause,  the  vertigo  is  due  to  an  involvement  of  the  ear- 
mechanism. 

1.  Lesions  in  the  ear  itself.  A  thorough  knowledge  of  the 
recent  advances  in  the  study  of  the  ear  is  of  prime  importance  to 
the  physician  even  from  the  standpoint  of  lesions  of  the  ear  itself. 
The  general  practitioner  is  familiar  with  conditions  of  the  ex- 
ternal ear,  the  middle  ear  and  the  cocJilear  portion  of  the  internal 
ear.  In  the  external  ear,  impacted  cerumen,  foreign  bodies,  eczema 
of  the  auditory  canal,  and  furunculosis — all  these  conditions  are 
obviously  purely  local  and  require  local  treatment.  In  the  middle 
ear  he  encounters  chronic  catarrhal  changes  producing  deafness, 
and  various  inflammatory  conditions.  To  be  sure,  some  of  the 
inflammatory  conditions  of  the  middle  ear  have  more  than  a  local 
significance ;  abscess  of  the  middle  ear  and  mastoid  empyema  may 


16  EQUILIBRIUM  AND  VERTIGO 

have  far-reaching  complications,  such  as  meningitis,  brain-abscess 
and  lateral  sinus  thrombosis.  Even  in  these  conditions,  however, 
the  ear  is  after  all  merely  the  local  source  of  infection.  Affections 
of  the  cochlear  joortion  of  the  internal  ear  are  made  manifest  by. 
impaired  hearing  and  noises  in  the  head;  the  attention  of  the 
l^hysician,  therefore,  is  immediately  called  to  the  ear;  in  fact  the 
patient  himself  recognizes  that  he  has  an  ear  disturbance.  A 
lesion  of  the  vestibular  portion  of  the  labyrinth  produces  dizziness, 
staggering,  nausea,  vomiting,  and  perhaps  diarrhoea,  just  as  an 
affection  of  the  cochlea  produces  noises  in  the  head.  When  con- 
fronted with  these  symptoms,  it  is  questionable  whether  at  the 
present  time  the  general  practitioner  is  apt  to  suspect  the  ear  as 
a  possible  source  of  all  these  phenomena.  The  external  ear,  the 
middle  ear,  and  the  cochlea,  are  of  interest  from  a  local  standpoint, 
^vhereas  the  equilibratory  portion  of  the  ear  is  part  and  parcel 
and  servant  of  the  whole  organism.  A  big,  strong,  healthy  man 
is  unable  to  stand  or  even  to  sit  up  in  bed,  because  of  a  slight 
congestion  of  the  internal  ear:  perhaps  the  pathologic  process 
has  produced  a  lesion  no  larger  in  extent  than  the  head  of  a  pin, 
yet  the  man  is  entirely  incapacitated.  Many  such  lesions  endan- 
ger the  life  of  the  patient  and  yet  may  readily  be  overlooked  unless 
the  physician  has  come  to  recognize  the  need  of  ear-examination. 
Non-inflammatory  conditions  of  the  inner  ear  may  be  pro- 
duced by  various  toxcTmias  or  by  hyperaemia  or  anaemia  of  the 
labyrinth ;  these  affections  are  productive  of  many  annoying  symp- 
toms—deafness, tinnitus,  vertigo  and  staggering— all  bad  enough 
in  their  way  and  also  disabling,  yet  at  the  same  time  not  serious 
in  the  sense  of  requiring  immediate  intervention  of  any  kind. 
Not  so  with  inflammatory  conditions  of  the  internal  ear;  here 
immediate  expert  attention  is  imperative  and  the  patient's  con- 
dition should  be  considered  grave.  Many  unfortunate  and  at  times 
tragic  errors  are  made  by  physicians  unacquainted  wdth  the  signifi- 
cance of  disturbances  of  this  type. 

Case  1.— John  B.,  aged  46.  August  3d,  1916,  he  felt  a  slight  itching  in  the  right 
ear  and  rubbed  his  ear  with  his  finger.  He  Avas  astonished  and  frightened  to  notice 
that  everything  in  the  room  rotated  rapidly.    However,  he  paid  no  more  attention  to 


THE  EAR  AND  THE  GENERAL  PRACTITIONER   17 

the  matter.  Two  days  later,  while  lying  in  bed  on  his  back,  he  rolled  over  to  the 
right  side  and  was  annoyed  to  find  that  the  bed  seemed  to  rise  on  the  left  side  and  he 
felt  that  he  was  falling  out  of  the  right  side  of  the  bed.  He  had  always  had  a  habit 
of  shaking  his  head  from  side  to  side  when  saying  "  No  "  in  convereation ;  he  found 
that  he  had  to  stop  this  habit,  as  it  caused  vertigo.  He  then  began  to  fear  that 
"  something  must  be  wrong  inside  his  brain."  and  consulted  his  family  physician, 
Dr.  Victor  Janvier,  who  elicited  a  history  of  purulent  discharge  off  and  on  from  the 
right  ear  for  over  -40  years,  following  scarlet  fever.  Although  there  had  been  no 
discharge  for  the  past  four  years,  he  recognized  that  the  ear  was  probably  the  cause 
of  all  the  symptoms.  Ear-examination  showed  necrosis  of  the  inner  wall  of  the 
middle  ear  with  a  fistula  leading  into  tlie  horizontal  semicircular  canal.  Local  treat- 
ment has  healed  over  this  fistulous  tract  and  has  also  apparently  cured  the  purulent 
middle-ear  condition.  The  man  is  not  only  entirely  free  from  all  attacks  of  vertigo, 
but  is  also  cured  of  a  condition  which,  if  neglected,  could  have  resulted  in  purulent 
labyrinthitis  and  meningitis. 

Case  2. — George  W.,  aged  30.  Three  weeks  before  admission  to  the  hospital, 
while  at  work,  was  suddenly  seized  with  dizziness,  severe  enough  to  make  him  fall 
over.  He  had  headache,  vomiting -and  diarrhoea  and  had  to  be  taken  home  and  put 
to  bed.  The  physician  consulted  thought  the  man  had  ''  stomach  trouble  "  and 
treated  him  accordingly.  The  vomiting  had  ceased,  but  as  the  vertigo  and  headache 
persisted,  the  patient  left  the  doctor  and  applied  to  a  medical  dispensary  for  treat- 
ment. The  physicians  there  thought  his  trouble  was  due  to  his  eyes  and  referred  him 
to  the  eye  department.  The  ophthalmologists  undertook  to  treat  the  case  and  pre- 
scribed a  mydriatic.  The  patient  was  not  getting  better  and  consulted  Dr.  Shmookler, 
who  found  that  thei'e  had  been  a  chronic  discharge  from  the  rig'ht  ear  since  child- 
hood. He  w^as  convinced  that  the  sj^mptoms  were  referable  to  the  ear  and  therefore 
sent  the  patient  to  the  hospital  again,  but  this  time  to  the  ear-sel•^•iee.  The  ear- 
examination  disclosed  a  circumscribed  labyi'inthitis — a  beginning  extension  into  the 
internal  ear  of  the  purulent  process  in  the  middle  ear — a  serious  condition  calling 
for  immediate  local  care  of  the  ear. 

Case  3. — Maurice  B.,  aged  51,  w^as  seized  with  dizziness,  staggering,  vomiting 
and  diarrhoea  on  board  ship,  coming  back  from  Europe.  The  ship's  doctor  naturally 
attributed  it  to  seasickness,  but  after  the  patient  reached  land  the  symptoms  did  not 
disappear.  A  few  weeks  later  the  vertigo  and  staggering  were  so  marked  that  he 
could  not  stand  nor  even  sit  up  in  bed.  Dr.  Kercher,  his  physician,  immediately 
suspected  that  it  was  an  ear-condition,  especially  as  the  patient  had  had  running 
ears  off  and  on  nearly  all  his  life.  On  examination  we  found  that  douching  the  left 
ear  failed  to  produce  the  nomial  responses  from  the  semicircular  canals,  namely, 
nystagmus,  vertigo,  past-pointing  and  falling.  This  demonstrated  an  involvement 
of  the  horizontal  canal  and  also  of  the  vertical  canals,  whereas,  although  the  hearing 
was  markedly  impaired,  the  cochlea  was  entirely  normal.  This  apparently  surprising 
phenomenon  was  easily  explained  as  due  to  an  extension  of  the  inflammation  from 
the  middle  ear  through  the  oval  wandoAv,  involving  the  end-organs  of  the  semi- 
circular canals,  but  so  limited  that  it  did  not  extend  foi"ward  into  the  cochlea.  Rest 
in  bed  and  local  treatment  of  the  ear  was  followed  by  uninterrupted  convalescence. 
A  mastoid  operation  should  now  be  done  to  cure  the  purulent  middle-ear  condition 


18  EQUILIBRIUM  AND  VERTKJO 

and  so  prevent  a  roenrrence  of  such  an  attack.  In  this  case,  according  to  old  stand- 
ards, with  a  perfectly  functionatinii'  cochlea,  not  the  slightest  earache,  no  discharge 
from  the  ear  or  lighting  up  of  an  old  middle  ear-suppuration,  and  with  the  patient 
himself  not  complaining  of  his  ear  nor  calling  attention  to  it,  there  was  nothing 
whatever  to  suggest  ear-involvement.  He  simply  presented  a  picture  of  a  big, 
healthy  man  unable  to  stand  up  because  he  was  dizzy.  It  was  only  this  doctor's 
familiarity  with  the  significance  of  dizziness  and  staggering  that  made  him  tliink  of 
the  ear. 

Case  4. — John  R.,  aged  58.  Attacks  of  vertigo  for  15  years  at  intervals  of  a 
year  or  six  months.  At  no  time  during  these  attacks  did  he  notice  any  tinnitus. 
Occasionally  when  attending  to  his  regular  business  he  felt  that  he  was  about  to  fall; 
thLs  sensation  passed  off  in  a  few  minutes.  Examination  showed  entirely  normal 
internal  ears  and  all  intracranial  pathways  from  the  ears.  Local  treatment  of  the 
left  middle  ear,  which  had  been  the  seat  of  occasional  discharge,  completely  cured  his 
attacks  of  vertigo  and  he  has  had  no  further  attacks  during  a  period  of  three  years. 

Summarizing,  inflammatory  conditions  of  the  middle  ear,  such 
as  an  acute  or  chronic  otitis  media  may  produce  only  irritative 
effects  upon  the  labyrinth,  so  that  the  i)atient  suffers  from  more 
or  less  vertigo  only  so  long  as  the  acute  stage  of  the  congestion 
lasts;  the  vertigo  vanishes  with  the  disappearance  of  the  inflam- 
mation. Slow  degenerative  changes  within  the  labyrinth  similarly 
produce  "attacks"  of  vertigo  from  time  to  time.  On  the  other 
hand,  sudden  destruction  of  the  whole  or  part  of  one  labyrinth  is 
accompanied  by  profound  vertigo,  nausea,  vomiting  and  loss  of 
equilibration.  Such  destruction  of  the  whole  or  part  of  the  laby- 
rinth may  be  produced  rarely  by  trauma,  but  usually  by  hemor- 
rhage or  serous  effusion  into  it,  and  may  occur  in  diabetes,  nephritis 
or  in  any  condition  in  which  the  vascular  system  is  affected.  It 
is  this  class  of  cases  that  exhibits  the  so-called  ''Meniere's  symp- 
tom-complex." The  hearing  in  these  cases  is  usually  markedly 
affected  if  not  altogether  gone,  and  the  condition  is  characterized 
by  an  attack  of  sudden  onset,  the  violence  of  the  symptoms  quickly 
reaching  a  climax  and  then  gradually  subsiding,  and  all  of  the 
symptoms  disappearing  when  the  brain-centres  have  learned  to 
compensate. 

When  a  patient  complains  of  dizziness  and  staggering,  with 
or  without  nausea  and  vomiting,  one  of  the  first  thoughts,  there- 
fore, should  be  of  a  possible  lesion  of  the  ear  itself. 


THE  EAR  AND  THE  GENERAL  PRACTITIONER   19 

2.  Lesions  within  the  brain,  causing  vertigo  by  affecting  the 
intracranial  pathways  from  the  ear,  such  as  tumor,  hemorrhage, 
thrombosis,  infarct,  abscess,  gumma,  tubercle,  leukcTmic  infiltration, 
specific  neuritis,  multiple  sclerosis,  syringomyelia,  polio-encepha- 
litis or  meningitis. 

The  value  of  ear-examination  in  the  differential  diagnosis  be- 
tween lesions  in  the  ear  and  lesions  in  the  brain  is  best  illustrated 
by  citing  two  cases.  In  one  case  the  history  and  symptoms  indi- 
cated a  lesion  of  the  ear,  and  yet  it  turned  out  to  be  an  intra- 
cranial lesion;  in  the  other  case,  the  history  and  symptoms  indi- 
cated an  intracranial  lesion  and  yet  it  turned  out  to  be  a  lesion 
in  the  ear. 

Case  5. — J.  B.  K.,  aged  39.  This  man,  in  September,  1914,  while  stepping  off  a 
train,  was  suddenly  seized  with  violent  vertigo,  nausea  and  vomiting.  The  vertigo 
was  so  severe  that  he  fell  to  the  platform,  and  was  taken  to  the  hospital  where  it 
was  necessary  to  keep  him  in  bed  for  ten  days ;  during  this  time  the  vertigo  gradually 
diminished.  The  patient  also  had  complete  deafness  in  the  right  ear.  Here  we 
have  the  typical  classical  picture  of  the  so-called  "  IMeniere's  disease  " — a  sudden 
hemorrhag-e  into  the  internal  ear.  Yet  it  turned  out  to  be  a  beginning-  tumor  in  the 
right  cerebello-pontile  angle  from  which  the  patient  died  in  seven  months. 

Case  6. — Mrs.  Agnes  G.,  aged  44.  July,  1914,  the  patient  srddenly  began  to 
have  diflieulty  in  walking-  and  in  September  had  severe  attacks  of  vertigo,  nausea  and 
projectile  vomiting.  The  diag-nosis  of  brain-tumor  was  made  and  neurologic  con- 
sultants found  that  the  symptoms  and  testS'  sug'gested  that  the  tumor  was  in  the 
right  cerebellar  hemisphere.  This  diagnosis  was  confirmed  by  the  X-ray  report, 
which  stated  that  it  was  a  cyst  in  the  right  cerebellar  hemisphere.  The  surg'eon  was 
about  to  operate,  but  hesitated  because  the  ear-examination  suggested  that  the  lesion 
was  in  the  right  labyrinth  and  that  the  cerebellum  appeared  normal.  The  past- 
pointing  after  ear-stimulation  Avas  nomial — both  arms  past-pointed  properly  both  to 
the  rig;ht  and  to  the  left.  The  patient  had  an  uninterrupted  convalescence  without 
operation,  has  given  birth  to  a  healthy  child  and  has  i-emained  in  perfect  health  ever 
since — two  and  one-half  years. 

3.  Ocular  conditions  producing  vertigo  are  naturally  best  stud- 
ied by  the  ophthalmologist.  If  the  ear-tests  fail  to  show  any  impair- 
ment of  the  ears  or  their  intracranial  pathways,  an  eye-examina- 
tion is  indicated.  Many  cases  of  vertigo  are  cured  by  correction  of 
ocular  defects.  Many  ophthalmologists  have  been  so  impressed 
with  the  number  of  cases  of  vertigo  cured  by  correction  of  ocular 
defects,  that  they  regard  the  eye  as  the  most  important  organ  in 


20  EQUILIBRIUM  AND  VERTIGO 

the  causation  of  vertigo.  The  eye,  however,  is  only  a  contributing 
cause  of  vertigo  in  certain  cases.  The  eye  is  not  the  organ  of 
balance.  If  an  eye  is  removed,  blindness  results,  but  no  vertigo; 
on  the  other  hand,  if  the  internal  ear  is  destroyed,  or  for  that  matter 
only  slightly  irritated,  there  immediately  result  vertigo  and  loss 
of  equilibration.  It  is  only  when  an  ocular  defect  as  in  muscle- 
paresis  affects  the  ear-mechanism  that  vertigo  results. 

4.  Involvement  of  tlie  ear-mechanism  by  cardiovascular  dis- 
turbance. This  classification  includes  all  cardiovascular  conditions 
which  produce  either  congestion  or  isch^emia  within  the  cranium. 
If,  as  in  shock,  there  occurs  a  cerebral  ischaemia,  the  temporarily 
poor  blood-supply  to  the  psychic  centres  causes  faintness  and  per- 
haps unconsciousness ;  similarly,  the  poor  blood-sup])ly  to  the  ear- 
mechanism,  either  peripheral  or  central,  produces  vertigo. 

5.  Toxaemias  affecting  the  ear-mechanism;  these  include 
ptomaine  poisoning,  alcoholism,  poisoning  by  chemicals  such  as 
lead,  quinine,  salicylates  of  soda ;  nephritis,  gout,  rheumatism, 
syphilis  and  the  toxaemia  of  infectious  fevers  such  as  mumps,  scar- 
latina and  typhoid  fever.  These  toxaemias  may  be  grouped  into 
two  classes. 

(a)  Evanescent  toxaemias  which  have  produced  no  degenera- 
tion of  the  cellular  elements  within  the  internal  ear  or  its  intra- 
cranial pathways. 

(b)  Toxaemias  which  have  produced  a  definite  impairment  of 
some  portion  of  the  ear  or  its  pathways. 

(a)  The  cases  of  evanescent  toxaemia  constitute  a  very  large 
proportion  of  the  cases  of  vertigo  that  are  seen  by  the  physician. 
The  simplest  illustration  of  this  type  of  vertigo  is  the  dizziness 
produced  by  the  ingestion  of  alcohol.  As  stated  previously,  the 
mere  presence  of  alcohol  in  the  stomach  does  not  produce  vertigo; 
it  is  only  when,  through  the  l)lood-stream,  the  alcohol  reaches  the 
ears  and  the  brain  that  the  individual  becomes  dizzy. 

Case  7. — l\Irs.  Van  S.,  aged  32.  This  patient  had  no  symptoms  referable  to 
her  ears,  but  was  referred  by  Dr.  John  McGlinn  because  she  complained  of  vertigo. 
In  October,  1913,  she  awoke  in  the  morning  with  a  violent  attack  of  vertigo,  accom- 
panied ])y  nausea,  retching-  and  diarrhoea.    The  attack  suggested  ptomaine-poisoning 


THE  EAR  AND  THE  GENERAL  PRACTITIONER   21 

in  every  particular,  except  that  there  was  no  pain  in  the  abdomen.  These  symptoms 
continued  for  40  hours,  and  then  the  patient  improved  progressively  for  the  follow- 
ing four  days.  On  the  fourth  day  she  was  out  of  bed  and  apparently  had  entirely 
recovered;  but  on  bending  over  to  kiss  her  boy  she  suddenly  felt  that  she  was 
plunging  forward  through  a  door.  This  second  attack  lasted  for  another  day. 
Gradual  improvement  followed,  so  that  at  the  time  of  the  ear-examination,  ten 
months  later,  she  stated  that  she  noticed  vertigo  only  when  she  lay  down  at  night. 
On  October,  1914,  she  awoke  in  the  morning  with  the  sensation  that  the  bed  was 
falling  over;  this  attack,  like  the  others,  gradually  diminished  in  severity  after  a  few 
days.  Between  the  attacks  she  merely  notices  that  when  she  goes  to  bed  at  night  it 
takes  her  about  half  an  hour  to  go  to  sleep  because  she  feels  a  little  dizzy,  and  that 
she  cannot  sew  or  read  because  it  makes  her  dizzy.  Examination  of  the  ears  showed 
normal  cochleae,  normal  semicircular  canals  and  normal  pathways  from  the  ear 
throughout  the  brain.  The  diagnosis  suggested  under  these  circumstances  was  that 
we  were  dealing  with  a  purely  functional  neurosis,  or  with  a  mild  toxic  irritation  of 
the  internal  ear.s.  On  receiving  this  report.  Dr.  McGlinn  recognized  that  the  prob- 
a;ble  source  of  this  toxsemia  was  a  pyurea  due  to  a  pyelitis  and  an  associated  cystitis. 
Under  the  vigorous  use  of  urotropin,  the  pyurea  was  markedly  impi'oved.  Dr. 
McGlinn  noted  distinctly  that  when  the  pyurea  was  most  marked,  her  vertiginous 
attacks  were  at  the  highest  and  that  when  the  pyurea  was  least  marked  there  was 
practically  no  vertigo.  During  the  past  year  and  a  half  she  has  been  practically 
free  from  either  the  pyurea  or  the  vertigo.  In  the  past  few  days,  however,  the 
pyurea  has  returned,  and  with  it  the  vertigo. 

(b)  Toxaemias  which  produce  a  definite  impairment  of  the  in- 
ternal ears  include  the  powerful  toxins  such  as  in  mumps  or 
syphilis,  and  also  the  repeated  assaults  of  a  milder  toxin  such  as 
those  from  the  gastro-intestinal  tract  or  from  a  focal  infection. 

Case  8. — Mrs.  W.,  aged  58.  The  patient's  first  attack  of  vertigo  occurred  in 
1897;  it  lasted  only  a  few  minutes;  she  had  three  or  four  attacks  during  the  next  14 
years.  A  severe  attack  in  1911  occurred  while  she  was  walking  along  the  street; 
these  attacks  came  on  at  irregular  intervals.  In  October,  1915,  a  severe  attack 
occurred  while  she  was  sitting  in  the  theatre  and  she  was  taken  to  the  hospital  where 
she  remained  for  seven  days.  Because  of  the  attacks  of  nausea,  vomiting,  diarrhoea 
and  emaciation,  a  diagnosis  was  made  of  gall-bladder  lesion;  oi^eration,  however, 
showed  the  gall-bladder  to  be  negative.  Subsequent  ear-examination  made  it  per- 
fectly simple  that  all  her  symptoms  had  been  due  to  recurrent  attacks  of  labyrinthine 
irritation.  Her  physician.  Dr.  R.  L.  Pitfield,  has  noted  that  when  she  eats  fish  or 
eggs  she  has  a  marked  gastro-intestinal  disturbance  and  that  vertigo  accompanies 
this  disturbance.  Under  dietetic  treatment  she  has  recovered  and  at  the  present  time 
is  in  excellent  health. 

Case  9. — Miss  C.  H.,  age  27.  This  patient  was  referred  by  Dr.  Francis  Packard, 
who  felt  it  advisable  to  remove  the  pathologic  tonsils,  but  hesitated  to  do  so  because 
the  patient  complained  of  severe  and  continuous  vertigo  for  a  period  of  over  six 


22  EQUILIBRIUM  AND  VERTIGO 

months.  This  dizziness  was  ahnost  continuously  i)resent ;  it  made  no  difference 
whether  she  was  lying  down  or  standing.  Occasionally  at  night  the  vertigo  would 
be  so  severe  as  to  wake  her  from  a  sound  sleep.  For  the  previous  year  or  two,  the 
patient  noticed  that  when  going  up  or  down  in  an  elevator  she  would  almost  faint ; 
six  months  ago,  however,  the  definite  vertigo  began  and  there  appeared  at  the  same 
time  ''  an  appearance  of  an  eruption  just  under  the  skin."  She  has  always  had 
exceptionally  good  health  until  this  skin-eruption  and  vertigo  commenced.  The 
report  of  the  ear-examination  read :  '"  There  is  no  evidence  of  any  intracranial  in- 
volvement along  any  of  the  pathways  from  the  ear.  There  is  a  proportionate  impair- 
ment of  nystagmus,  vertigo  and  past-pointing,  indicating  a  slight  impairment  of 
function  of  the  vestibular  portion  of  the  right  labyrinth.  The  diagnosis  suggested 
is  a  toxfemia  which  has  affected  the  internal  ears  at  intervals,  thus  producing  the 
vertiso;  the  condition  is  in  no  sense  serious.  If  the  toxfemia  can  be  eliminated  it  is 
possible  she  will  have  no  more  attacks  of  vertigo."  Dr.  Packard  removed  the  tonsils; 
in  a  few  days  there  was  a  complete  disappearance  of  the  vertigo  and  the  skin 
eruption  also  disappeared  at  the  same  time. 

Case  10. — Hugh  H.,  aged  42.  The  patient  was  referred  by  Dr.  Vincent  Lyon 
with  a  histoiy  of  an  attack  nine  months  before  of  acute  articular  rheumatism  involv- 
ing almost  all  the  joints.  At  the  time  the  patient  was  confined  to  the  hospital  for  17 
days  and  after  leaving  the  hospital  continued  to  have  occasional  recurrence  of  the 
involvement  of  the  joints.  Three  months  after  the  original  attack,  the  patient  began 
to  complain  of  vertigo  and  staggering  and  was  refei-red  for  an  examination  of  the 
ear  in  the  attempt  to  discover  the  cause  of  tlie  vertigo.  The  ear  report  read  "Exam- 
ination shows  a  distinct  impairment  of  both  internal  ears,  in  both  the  cochlear  and 
vestibular  portions.  This  suggests  that  a  source  of  toxaemia  must  be  searched  for. 
It  raav  be  that  the  same  toxic  substance  that  causes  his  joint  involvement  has  also 
caused  this  toxic  labyrinthitis."  X-ray  showed  abscesses  at  the  roots  of  two  teeth; 
these  abscesses  were  drained  by  the  removal  of  these  two  teeth.  Within  a  week  the 
patient  ceased  to  have  any  vertigo  or  staggering,  and  also  all  the  rheumatic  symp- 
toms entirely  disappeared.  That  the  removal  of  the  focal  infection  at  the  roots  of 
the  teeth  cured  this  patient  entirely  of  all  his  symptoms  makes  it  strongly  suggestive 
that  this  focal  infection  was  responsible  for  his  entire  illness;  the  toxaemia  on  the 
one  hand  had  involved  the  joints  and  on  the  other  hand  had  involved  the  internal 
ears,  thus  producing  the  vertigo  and  staggering. 

Summarizing  therefore : 

1.  Vertigo  from  whatever  cause  is  a  disturbance  of  the  ves- 
tibular apparatus,  which  we  have  spoken  of  as  the  ear-mechanism. 

2.  Disturbances  of  the  vestibular  apparatus  can  be  definitely 
analyzed  by  means  of  the  ear-tests. 

3.  Cases  of  vertigo  need  no  longer  be  regarded  as  vag-ue  or 
mysterious  but  may  now  be  cleared  up  by  means  of  the  ear-tests. 
Vertigo,  therefore,  need  no  longer  be  a  term  wherein  to  cloak 


THE  EAR  AND  THE  GENERAL  PRACTITIONER   23 

our  ignorance  as  to  the  many  diverse  conditions  of  which  it  is 
a  symptom. 

In  any  given  case  of  vertigo  the  first  thing  to  be  done  is  to 
examine  this  ear-mechanism  that  is  responsible  for  the  vertigo. 
The  ear-tests  will  always  show  either  abnormal  or  normal  re- 
sponses ;  if  the  responses  are  abnormal,  the  tests  will  help  to  deter- 
mine a  lesion  either  within  the  ear  or  within  the  brain.  If  the 
responses  are  normal  we  have  then  narrowed  the  diagnosis  down  to 
(1)  a  purely  functional  neurosis,  (2)  an  ocular  disturbance,  or 
to  an  evanescent  toxaemia  the  source  of  which  must  then  be  looked 
for.  The  ear-examination,  to  be  sure,  does  not  determine  every- 
thing whatsoever  that  has  to  do  with  vertigo,  but  it  certainly  brings 
order  out  of  chaos  in  these  cases  and  makes  i)ossible  accurate 
diagnosis  and  intelligent  treatment.  A^ertigo,  therefore,  is  essen- 
tially an  ear  study. 

The  methods  of  carrying  out  the  ear-tests  are  described  in 
Part  II  of  this  book. 


CHAPTER  III 

THE  EAR  AND  AVIATION 

At  the  present  hour  perhaps  the  most  valuable  service  that 
the  otologist  can  render  to  the  Government  is  in  the  Aviation 
Service.  In  aviation  we  have  a  practical  example  of  the  impor- 
tance of  the  ear  in  maintaining  equilibrium.  It  has  been  noted 
in  the  previous  chapter  that  after  the  loss  or  impairment  of  one 
of  the  three  senses  responsible  for  equilibrium,  compensation 
may  take  place  to  a  certain  extent.  It  is  not  necessary  for  an 
individual  to  have  a  perfect  muscle-sense,  perfect  sight,  and  per- 
fect internal  ears  in  order  to  have  fairly  good  equilibrium;  this, 
however,  takes  for  granted  that  the  individual  is  on  "terra  firma." 
When  the  human  being  becomes  a  bird,  as  it  were,  he  suddenly 
finds  himself  in  an  entirely  new  environment.  Without  function- 
ating internal  ears  it  is  impossible  for  an  individual  to  be  a  good 
bird-man.  When  flying  through  the  air,  on  what  does  the  aviator 
rely  in  order  to  maintain  his  equilibrium  and  that  of  the  aeroplane? 
Can  he  rely  on  sight?  Hardly,  for  when  he  is  sailing  through  the 
clouds  or  darkness,  his  eyes  cannot  give  him  the  slightest  infor- 
mation about  his  position  in  space — not  even  whether  he  is  right 
side  up  or  upside  down.  As  regards  the  muscle-sense,  it  is  un- 
doubtedly true  that  it  plays  a  certain  part;  but  when  the  aviator 
is  seated  on  an  unstable  and  rapidly  moving  machine,  it  is  hardly 
conceivable  that  the  weight  of  his  body  could  determine  and  main- 
tain his  position  in  space  merely  by  the  sensing  of  gravity.  In 
order,  therefore,  to  preserve  that  wonderful  accuracy  necessary  in 
controlling  such  a  delicate  mechanism  as  the  flying  machine,  he 
relies  pre-eminently  on  his  ear  balance-sense.  It  is  easily  conceiv- 
able that  some  of  the  unexplained  accidents  in  aviating  may  be 
due  to  a  concussion  of  the  internal  ear  produced  either  by  the 
deafening  roar  of  the  engine  or  by  the  decrease  of  the  air-pressure 
when  at  great  heights.    Also  in  a  rapid  ascent  from  a  denser  to  a 

24 


THE  EAR  AND  AVIATION  25 

rarer  air  there  occurs  an  oxygen  insufficiency  which  has  a  direct 
effect  upon  the  ear-mechanism  through  the  blood-stream.  It  is 
also  highly  probable  that  many  an  aviator  has  gone  to  his  death 
because,  all  unknown  to  him,  he  did  not  possess  a  normal  ear- 
mechanism  ;  in  the  presence  of  a  combination  of  difficulties  in  which 
all  normal  faculties  would  be  requisite,  he  was  unable  to  maintain 
his  balance  because  of  an  imperfect  ear-mechanism. 

To  realize  the  importance  of  the  ear  in  the  matter  of  flying, 
it  is  only  necessary  to  consider  a  bird  flying  in  a  cloud.  His  muscle- 
sense  naturally  means  nothing  to  him;  his  sight  is  of  no  help. 
He  relies  exclusively,  therefore,  upon  normal  functionating  semi- 
circular canals,  which  we  know  are  wonderfully  well  developed  in 
the  bird. 

Summarizing,  therefore,  even  when  an  individual  is  standing  or 
walking  on  the  earth,  his  ears  constitute  his  sense-organs  of 
balance;  as  long  as  he  remains  upon  the  earth  he  has  in  addition 
the  contributory  help  of  information  received  from  his  muscle- 
sense  and  his  sight.  Wlien  he  rises  above  the  earth  and  flies  in 
the  dark  it  is  obvious  that  these  contributory  factors  are  prac- 
tically eliminated  and  he  must  reh^  almost  exclusively  upon  the 
ear  balance-sense. 

Since  normal  internal  ears  are  such  an  important  asset — in 
fact  a  prime  requisite — for  the  aviator,  common  prudence  would 
suggest  a  most  careful  examination  of  the  degree  of  function  of 
one's  internal  ears  before  taking  up  flying  as  an  occupation.  The 
ear-tests  furnish  exact  and  mathematical  data  concerning  not  only 
the  function  of  the  internal  ear,  but  also  of  the  entire  vestibular 
apparatus;  this  includes,  besides  the  ears  themselves,  the  VIII 
Nerve,  the  brain-stem,  the  cerebellum  and  the  entire  balance- 
mechanism. 

When  it  was  announced  that  a  state  of  war  existed  between 
the  United  States  and  Germany,  it  at  onc.e  became  apparent  that 
a  tremendous  number  of  aviators  must  be  secured  for  the  mili- 
tary service  within  the  shortest  possible  space  of  time.  The  medical 
problem  consisted  of  selecting  thousands  of  physically  equipped 
candidates  for  aviation  and  placing  them  in  training  for  war- 


^2Q  EQUILIBRIUM  AND  VERTIGO 

service  immediately.  The  medical  department  found  it  necessary 
to  decide  upon  new  methods  of  physical  examination  and  to  adopt 
new  standards  of  physical  qualifications  for  this  branch  of  the 
service.  This  had  to  be  done  not  merely  for  one  place  or  for  one 
examining  group;  it  was  necessary  to  make  the  tests  practicable 
for  cities  in  all  parts  of  the  United  States,  without,  at  the  same 
time,  in  any  way  lowering  the  requisite  rigid  standards  or  lessen- 
ing the  completeness  of  the  examination.  How  could  this  be  done? 
In  a  word,  such  an  ideal  could  be  attained  only  by  (1)  the  standard- 
ization of  the  tests,  and  (2)  the  standardization  of  the  examiners. 
The  methods  presented  in  this  book  were  adopted  in  May, 
1917,  as  the  standard  for  the  U.  S.  Army.  The  following  briefly 
summarizes  the  fundamental  principles  underlying  the  examination 
for  aviators.  The  aviator  must  be  in  a  sense  the  ''superman." 
He  must  have  20/20ths  vision  without  glasses.  He  must  have 
40/40ths  hearing.  Such  requirements  are  higher  than  for  most 
branches  of  military  service.  A  candidate  for  every  branch  of 
service  must  conform  to  a  certain  physical  standard;  he  must 
be  a  normal  man,  such  as  w^ould  satisfy  the  average  life  insurance 
company,  wdth  the  additional  requirements  of  a  certain  relative 
height,  weight  and  chest  measurement  and  a  definite  visual  and 
auditory  acuity.  Like  any  other  candidate  for  service,  the  aviator 
must  conform  to  all  these  requirements  and  in  addition  must  pos- 
sess visual  and  auditory  acuity  to  a  high  degree.  There  is,  how- 
ever, an  attribute  not  required  by  any  other  branch  of  the  military 
service  which  is  indis]iensable  to  the  ])erfect  aviator — a  good 
halance-mechanism.  Therefore  the  peculiar  test,  applied  to  the 
aviator  alone,  is  the  special  examination  of  the  equilibratory  por- 
tion of  the  internal  ear. 

Official  Blank 

physical  examination  of  applicants  for  detail  in  the  aviation 

section,  signal  corps,  v.  s.  army 

equilibrium  (vestibular  tests ) 
The  nystagmus,   past-pointing  and  falling  after  turning,   are 
tested.     The  turning-chair  must  have  a  head-rest  which  will  hold 
the  head  80^  forward,  a  foot-rest  and  a  stop-pedal.     (The  chair 


THE  EAR  AND  AVIATION  27 

shown  on  page  235  is  officially  required.  This  made  possible  the 
establishment  of  an  absolute  standard.  While  the  tests  could  be 
made  by  using  other  types  of  turning-chair,  an  exact  quantitative 
estimation  of  the  responses  can  be  definitely  established  only  by 
the  use  of  a  standardized  chair.) 

{a)  Nystagmus.  First  of  all  a  spontaneous  nystagmus  must 
be  looked  for.  It  is  noted  whether  there  is  any  twitching  of  the 
eyes  when  gazing  straight  ahead,  or  looking  either  to  the  extreme 
right,  the  extreme  left,  up  or  down.  Head  forward  SO"" ;  turn  can- 
didate to  the  right,  eyes  closed,  10  turns  in  20  seconds.  The 
instant  the  chair  is  stopped,  click  the  stop-watch ;  candidate  opens 
his  eyes  and  looks  straight  ahead  at  some  distant  point.  There 
should  occur  a  horizontal  nystagmus  to  the  left  of  26  seconds' 
duration.  Candidate  then  closes  his  eyes  and  is  turned  to  the  left ; 
there  should  occur  a  horizontal  nystagmus  to  the  right  of  26 
seconds'  duration.  A  variation  of  10  seconds  is  allowable  (either 
as  low  as  16  seconds  or  as  high  as  36  seconds). 

{h)  Pointing: 

1.  Candidate  closes  eyes,  sitting  in.  chair  facing  examiner, 
touches  examiner's  finger  held  in  front  of  him,  raises  his  arm  to 
the  perpendicular  position,  low^ers  the  arm  and  attempts  to  find 
the  examiner's  finger.  First  the  right  arm,  then  the  left  arm.  The 
nonnal  is  always  able  to  find  the  finger. 

2.  The  pointing  test  is  repeated  after  turning  to  the  right, 
10  turns  in  10  seconds.  During  the  last  turn,  the  stop-pedal  is 
released  and  as  the  chair  comes  into  position,  it  becomes  locked. 
The  right  arm  is  tested,  then  the  left,  then  the  right,  then  the  left, 
until  candidate  ceases  to  past-point.  The  absolutely  normal  will 
past-point  to  the  right  3  times  with  each  arm,  if  needless  delay 
is  avoided.  (However,  one  past-pointing  to  the  right  of  each  arm 
qualifies,  if  the  nystagmus  and  falling  are  normal.) 

3.  Repeat  pointing-test  after  turning  to  the  left.  (Similarly 
one  past-pointing  of  each  arm  to  the  left  qualifies,  if  the  nystagmus 
and  falling  are  normal.) 

(c)  Falling.  Candidate's  head  is  inclined  120°  forward,  eyes 
closed.    Turn  to  the  right,  5  turns  in  10  seconds.    On  stopping,  can- 


28  EQUILIBRIUM  AND  VERTIGO 

didate  quietly  sits  up  and  should  fall  to  right.  This  tests  the 
vertical  semicircular  canals.  Turn  to  the  left,  head  forward  120° ; 
on  stopping,  the  candidate  again  sits  up  and  should  fall  to  the  left. 


Obviously  these  tests  as  presented  in  this  blank  are  not  in- 
tended to  make  a  diagnosis  of  a  pathologic  lesion.  The  object  is 
merely  to  determine  whether  or  not  the  ear-mechanism  is  normal. 
If,  in  these  tests,  the  candidate  shows  normal  responses  in  nys- 
tagmus, past-pointing  and  falling,  he  is  fit  for  the  aviation  service ; 
if  he  does  not,  he  is  unfit  for  that  service.  These  simple  turning 
tests  eliminate  all  unnecessary,  time-consuming,  diagnostic  pro- 
cedures. The  entire  series  of  tests  as  outlined  in  the  blank  requires 
only  334  minutes ;  and  yet  in  this  short  time  we  are  able  to  deter- 
mine the  integrity  of  the  internal  ears,  the  VIII  Nerves,  and  the 
pathways  through  the  medulla  oblongata,  the  pons,  the  six  cerebel- 
lar peduncles,  the  cerebellum  itself  and  the  cerebral  crura  to  the 
cerebral  cortex — the  "balance-mechanism." 

Incidentally,  these  tests  are  in  no  sense  severe  and  are  in  fact 
seldom  regarded  even  as  unpleasant.  Occasionally  nausea  occurs 
after  a  few  turnings ;  it  is  then  merely  necessary  to  stop  the  ex- 
amination for  the  time  being  and  to  complete  the  remainder  of  the 
tests  after  an  interval  of  a  half-hour.  There  is  no  need  whatever 
to  make  these  tests  in  any  way  distressing  to  the  candidate. 

These  turning-tests  quickly  separate  the  obviously  fit  from  the 
unfit.  The  majority  of  the  candidates  show  normal  responses;  no 
further  testing  is  required  and  they  therefore  qualifj^  and  are 
accepted.  Some  candidates  show  such  markedly  subnormal  re- 
sponses that  they  are  immediately  disqualified  and  rejected.  A 
limited  number  give  Avliat  might  be  termed  "border-line"  re- 
sponses; the  question  then  arises,  has  this  particular  applicant 
sufficient  balance-sense  to  become  an  aviator?  It  is  here  that  the 
caloric  test  is  useful.  The  turning  has  tested  botli  the  right  and 
left  ears  simultaneously.  The  caloric  method  enables  us  to  test 
each  ear  separately.  Water  at  68°  F.  is  allowed  to  run  into  the 
external  auditory  canal  from  a  height  of  about  3  feet  through  a 
stop-nozzle,  with  the  head  tilted  30°  forward,  until  the  eyes  are 


THE  EAR  AND  AVIATION  29 

seen  to  jerk  or  the  individual  becomes  dizzy.  The  length  of  time 
from  the  beginning  of  the  douching  until  the  jerking  of  the  eyes 
becomes  apparent,  or  until  the  applicant  says  he  is  dizzy,  is  accu- 
rately measured  by  a  stop-watch.  The  type  of  nystagmus  is  then 
noted.  It  should  be  rotary  and  the  direction  of  the  jerk  should 
be  to  the  side  opposite  the  ear  douched.  The  length  of  time  shown 
by  the  stop-watch  in  the  normal  is  40  seconds.  The  eyes  are  then 
closed  and  the  past-pointing  is  taken.  The  head  is  then  imme- 
diately inclined  backward  60°  from  the  perpendicular  (or  90° 
from  the  original  position).  There  should  then  appear  a  horizontal 
nystagmus  to  the  side  opposite  to  the  ear  douched.  The  eyes  are 
then  closed  and  the  past-pointing  is  taken  with  the  head  in  this 
position.  The  left  ear  is  then  douched  and  the  same  procedure 
carried  out.  If  the  caloric  test  applied  to  one  of  these  ^'border- 
line" cases  shows  only  a  slight  impairment  of  the  responses  from 
each  ear,  the  candidate  is  qualified.  A  slight  impairment  w^ould  be 
indicated  if  instead  of  the  normal  40  seconds  of  douching,  there 
was  required  not  more  than  90  seconds  of  douching.  If  one  ear 
shows  normal  responses,  whereas  the  other  ear  shows  responses 
only  after  more  than  90  seconds  of  douching,  the  candidate  is  dis- 
qualified. Care  should  be  taken  to  be  certain  that  the  cold  water 
is  reaching  the  drum-head  during  this  caloric  test,  as  wax  or  other 
obstruction  in  the  external  canal  would  interfere  with  the  responses 
in  a  perfectly  normal  individual. 

The  examination  of  a  candidate  for  the  aviation  service  is  a 
different  matter  from  the  examination  of  a  patient.  We  are 
dealing  with  an  alert  mind,  anxious  to  make  the  best  showing 
possible.  Many  candidates  feel  that  "jumping  eyes"  and  evi- 
dences of  vertigo  are  signs  of  weakness  and  would  be  counted 
against  them.  Because  of  this  anxiety,  many  candidates  attempt 
to  shorten  the  duration  of  the  nystagmus  by  fixing  the  eyes  on  some 
near  object.  It  is  perfectly  possible  by  fixing  of  the  eyes  to  shorten 
the  duration  of  the  nystagmus.  It  is  a  common  experience  in  this 
work  to  note  that  when  many  observers  are  standing  about  the 
candidate  and  in  his  line  of  vision  that  the  nystagmus  is  usually 
of  short  duration.     If  these  observers  are  asked  to  stand  back  out 


30  EQUILIBRIUM  AND  VKRTKJO 

of  the  line  of  vision,  the  same  candidate  almost  invariably  shows 
a  longer  duration  of  nystagmus.  Further  to  obviate  fixation  of 
the  eyes,  it  is  always  necessary  to  place  the  chair  near  a  large 
window  so  that  the  candidate  has  an  unobstructed  view  of  an 
object  placed  at  "infinity" — over  20  feet.  Furthermore,  instead 
of  obeying  the  natural  impulse  to  past-point,  they  frequently  make 
a  mental  calculation  as  to  the  vertigo  induced  and  voluntarily'- 
attempt  not  to  past-point.  This  is  also  true  of  falling.  In  such 
instances,  the  examiner,  bearing  in  mind  the  type  of  individual 
with  w^hom  he  is  dealing,  urges  the  ai)plicant  to  "act  perfectly 
naturally,"  and  is  then  usually  able  to  elicit  a  true  response  to 
the  test.  Supposing,  however,  that  the  candidate  still  fails  to 
past-point,  although  he  has  shown  a  normal  nystagmus  and  falling 
■ — we  are  able  to  decide  the  matter  finally  in  the  following  way: 
First,  the  quantitative  estimation  of  vertigo  is  taken.  The  after- 
turning  vertigo  is  measured  as  follows :  Candidate  is  turned  to  the 
right,  10  turns  in  10  seconds,  with  eyes  closed,  as  follows:  As  he  is 
being  turned,  he  is  asked  to  describe  his  sensations  and  to  keep  on 
telling  in  which  direction  he  feels  he  is  being  turned;  thus  he  will 
say  "to  the  right,  to  the  right,  to  the  right,"  etc.,  until  the  chair 
is  stopped,  then  he  will  feel  himself  turning  in  the  opposite  direc- 
tioa[ii,aiad  will  say,  "Now  I  am  going  to  the  left,  to  the  left,  to  the 
leftyfi'ijisite.,  when  as  a  matter  of  fact  he  is  sitting  perfectly  still  in 
the!,,ehaLr.  The  duration  of  this  sensation  of  vertigo  from  the 
time  that  the  chair  is  stopped  until  he  ceases  to  feel  that  he  is 
gi(j]()iii^hto  the  left  is  taken  in  seconds  with  the  stop-watch.  The  nor- 
mal should  show  an  after-turning  vertigo  of  26  seconds.  The  test 
is  then  repeated  by  turning  to  the  left  and  the  candidate  should 
exhibit  a  vertigo  in  the  opposite  direction  of  26  seconds.  Should 
the  candidate  show  over  16  seconds  of  vertigo  in  both  directions, 
having  previously  shown  a  normal  nystagmus  and  falling,  the 
examiner  then  realizes  that  the  absence  of  past-pointing  was  prob- 
ably due  to  a  calculated  correction  rather  than  to  any  pathologic 
condition.  The  question  is  then  definitely  determined  by  douching 
the  ears.  Although  a  candidate  can  estimate  the  significance  of  the 
sensation   of  vertigo  after  turning,  he  has   no  control   over  this 


THE  EAR  AND  AVIATION  31 

sensation  after  douching;  he  is  unable  to  calculate  the  meaning  of 
the  vertigo  produced  by  the  caloric  test.  Therefore,  if  he  fails 
to  past-point  after  the  douching-tests,  he  is  definitely  disqualified. 

So  much  for  the  standardization  of  the  tests  themselves. 
Equally  important  was  the  problem  of  the  standardization  of 
the  examiners.  For  this  purpose  a  medical  officer  was  sent  under 
special  orders  to  each  of  35  cities  throughout  the  United  States 
and  in  each  one  of  these  cities  there  was  established  a  medical  unit 
for  the  examination  of  candidates  for  the  aviation  service.  The 
requirements  of  the  tests  were  fully  explained  to  each  medical 
unit,  so  that  not  only  the  same  equipment  is  used,  but  also  exactly 
the  same  technic.  This  rendered  it  impossible  for  any  candidate 
to  say,  "I  wish  I  had  been  examined  in  a  certain  city  where  the  tests 
are  easy,  rather  than  in  a  certain  other  city  where  the  tests  are 
exacting."  Those  otologists  were  selected  who  were  most  expert 
in  the  Barany  tests  and  they  were  given  intensive  training  by  the 
medical  officer  sent  for  the  purpose  of  establishing  a  uniform, 
technic.  Thus  in  a  few  months  the  testing  was  put  on  an  absolutely 
uniform  basis  in  all  examining  centres. 

In  order  to  save  time,  already  existing  institutions,  such  as 
large  hospitals  or  State  Universities,  with  their  equipments,  were 
utilized  as  these  examining  centres.  Volunteer  staffs  o^  <jivilian 
consultants  were  locally  organized  and  the  work  of  the  examining 
centres  systematized  to  a  point  of  highest  efficiency,  with  tbe^-esult 
that  within  a  few  days  of  the  arrival  of  the  medical  officer  at  the 
examining  centre  the  work  was  in  full  swing.  By  this  nieMa»drof 
decentralization,  the  examination  of  thousands  of  ap])licnnts  in  a 
minimum  space  of  time  was  made  possible.  First  of  all  it  was 
necessary  to  make  sure  that  those  in  charge  of  each  examining 
centre  were  fully  equipped  and  capable  to  make  these  tests;  this 
once  assured,  full  authority  and  responsibility  was  vested  in  the 
medical  officer  in  charge  of  each  centre.  Thirty-five  medical  avia- 
tion centres,  each  examining  from  ton  to  forty  candidates  a  day, 
provided  immediately  the  thousands  of  men  required. 

It  is  obvious  to  the  candidate  himself,  that  if  he  is  deficient 
in  his  ear  balance-sense  he  is  not  onlv  a  danger  to  the  Service, 


32  EQUILIBRIUM  AND  VERTIGO 

but  lie  is  also  unnecessarily  imperiling  his  own  life  when  he 
attempts  to  fly.  Certain  members  of  the  medical  profession  and 
certain  veteran  fliers,  because  of  the  newness  of  these  methods, 
expressed  skepticism  in  regard  to  their  value.  One  physician,  a 
member  of  an  examining  unit,  was  surprised  to  find  that  when  he 
himself  was  examined,  he  showed  an  almost  complete  lack  of  ear 
balance-sense.  The  turning  and  caloric  tests  failed  to  produce 
nystagmus,  vertigo,  past-pointing  and  falling.  This  impairment 
of  the  ear-mechanism  was  directly  traceable  to  a  severe  attack  of 
mumps  ill  childhood,  during  which  he  had  suffered  from  both  of  the 
usual  complications  of  mumps — an  orchitis  and  an  involvement  of 
the  internal  ears.  His  skepticism  was  changed  to  enthusiastic  con- 
viction when  he  thus  was  made  to  realize  that  without  the  Barany 
tests  he  would  have  had  no  conception  of  this  physical  disability, 
the  only  suggestion  of  which,  up  to  that  time,  had  been  his  knowl- 
edge that  he  was  unable  to  become  seasick. 

All  experienced  aviators  that  have  been  examined  have,  without 
exception,  shown  normal  responses  in  tlie  turning-chair.  Those 
veteran  aviators  whose  attention  has  been  called  to  these  methods 
of  testing,  have  expressed  their  conviction  of  the  practicability 
of  the  safeguards  provided  by  these  tests  in  determining  whether 
or  not  a  man  has  what  they  speak  of  as  "  air-sense. ' '  One  seasoned 
American  flier,  of  15  years'  experience,  stated  that  his  doubt  was 
changed  to  conviction  after  he  was  examined  in  the  turning-chair ; 
he  volunteered  a  statement  that  from  his  intimate  knowledge  of 
the  circumstances  attending  the  death  of  at  least  three  aviators, 
who  were  killed  while  flying,  their  failure  to  negotiate  difficulties 
of  no  unusual  degree  which  resulted  in  their  death,  might  now 
be  understood  as  an  expression  of  their  lack  of  this  sense.  He 
further  added,  that  in  his  judgment,  if  these  tests  had  been  avail- 
able in  the  early  days  of  flying,  many  lives  might  have  been  spared. 

The  value  of  the  past-pointing  test  is  well  illustrated  by  one 
candidate  who  proved  to  have  a  post-traumatic  cerebellar  lesion, 
which  was  first  detected  by  the  isolated  absence  of  past-pointing 
of  the  left  aiTn  to  the  right.  Neurologic  examination  then  demon- 
strated classical  signs  of  lesion  of  the  left  cerebellar  hemisphere. 


THE  EAR  AND  AVIATION  33 

Here  was  a  man  with  distinctly  impaired  cerebellar  function 
attempting  to  enter  a  service  in  which  the  utmost  demands  are 
made  upon  the  cerebellum. 

One  ardent  applicant  was  disqualified  because  of  a  markedly 
impaired  internal  ear,  in  both  the  cochlear  and  vestibular  portions. 
It  has  since  been  learned  that  he  went  to  another  country  where 
he  was  accepted  in  the  aviation  service  as  a  flier.  Obviously  the 
requirement  in  that  country  is  not  so  high  as  in  the  United  States. 
At  the  present  time  in  the  United  States  a  high  standard  is  required 
because  this  countiy  is  in  a  position  to  pick  and  choose.  The  vast 
numbers  of  splendid  applicants  makes  this  possible.  For  this 
reason  these  hand-]ncked  men  will  constitute  not  only  the  largest 
but  the  most  capable  and  finest  aviation  service  in  the  world. 


CHAPTER  IV 
THE  EAR  AND  SEASICKNESS 

"Mal-de-mer"  is  a  phenomenon  resulting  from  movement  of 
the  endolymph  within  the  internal  ear.  The  history  of  seasick- 
ness dates  as  far  back  as  man's  first  attempts  to  brave  the  dangers 
of  the  sea.  It  is  difficult  to  understand  why  the  ease  with  which 
one  succumbs  to  seasickness  should  always  have  been  a  subject 
of  ridicule,  but  the  literature  of  all  nations  abounds  witli  gibes 
and  jests  about  the  sufferer  from  mal-de-mer.  Those  who  have 
been  subjected  to  it,  however,  can  state  with  a  good  deal  of  assur- 
ance that  it  is  distinctly  a  serious  matter,  deserving  as  much  sym- 
pathetic consideration  as  any  other  distressing  ailment. 

Theories  as  to  the  cause  of  this  malady  and  remedies  suggested 
for  its  relief  have  been  innumerable  and  with  the  advent  of  each 
new  explanation  would  come  a  host  of  remedies  for  its  prevention 
and  cure.  A  perusal  of  the  literature  on  the  subject,  which  is 
enormous,  shows  that  every  drug  in  the  pharmacopoeia  has  been 
considered  useful ;  this  of  itself  signifies  that  nothing  really  useful 
had  been  discovered.  The  medical  profession,  appealed  to  from 
time  immemorial  by  a  suffering  traveling  public,  could  afford  no 
relief;  so  it  is  no  wonder  that  even  today  thousands  of  people 
would  not  think  of  going  to  sea  without  protecting  themselves,  as 
they  think,  Avith  some  remedy  suggested  by  some  friend  who  has 
considered  it  useful,  such  as  a  belladonna  plaster,  a  sheet  of  fools- 
cap paper,  or  other  applications  over  the  abdomen. 

Without  a  knowledge  of  the  true  etiology  of  this  condition,  the 
only  treatment  that  appeared  at  all  rational  was  the  sym]itomatic; 
as  nausea  and  vomiting  are  the  most  evident  and  predominant 
symptoms,  everything  centred  about  remedies  which  were  supposed 
to  relieve  these  symptoms.  It  is  of  course  easy  to  see  why  there 
should  have  been  the  gastric  theorj^  of  the  causation  of  this  malady; 
nausea  and  vomiting  naturally  suggested  a  "bad  stomach,"  Based 
upon  this  theory,  some  were  advised  not  to  eat  at  all  or  only  very 

34 


THE  EAR  AND  SEASICKNESS  35 

little,  whereas  others  were  advised  to  indulge  in  a  liberal  diet. 
This  theory,  however,  has  come  to  be  disregarded;  any  observing 
clinician  could  no  more  ascribe  the  nausea  and  vomiting  of  ynal-de- 
mer  to  a  gastric  affection  than  he  could  ascribe  the  nausea  and 
vomiting  associated  with  brain  tumor  or  meningitis  to  a  disturb- 
ance in  the  stomach. 

The  optic  theory  was  in  vogue  for  a  considerable  time  and 
had  many  adherents.  According  to  this  explanation,  individuals 
were  seasick  because  of  the  ever-changing  images  on  the  line  of  the 
horizon  and  of  the  swaying  decks  and  spars.  The  observation 
that  the  administration  of  atropin  seemed  to  be  helpful  appeared 
to  lend  considerable  credence  to  this  view.  For  a  while  atropin- 
blinded  individuals,  wearing  violet-tinted  glasses,  were  quite 
numerous  aboard  every  ocean-bound  vessel.  The  fact,  however, 
that  seasickness  did  not  spare  individuals  who  were  asleep  in 
their  darkened  berths  soon  furnished  an  insuperable  obstacle  to 
the  correctness  of  this  theory;  and  it  soon  lost  its  hold  upon  the 
traveling  public. 

The  flushed  appearance  of  an  individual  prior  to  succumbing 
to  the  malady  suggested  to  some  that  a  cerebral  congestion  was 
the  basic  underlying  factor;  on  the  other  hand,  the  anjcinic  pallor 
gave  origin  to  a  theory  of  cerebral  ischccmia.  One  author  an- 
nounced a  positive  cure  for  seasickness  without  the  use  of  drugs, 
laying  the  blame  for  seasickness  on  the  maintaining  of  a  tense 
musculature  while  on  board  ship  and  suggested  that  all  the  indi- 
vidual need  do  is  to  relax  completely  and  to  assume  the  swagger- 
ing gait  of  the  hardened  sea-dog  to  do  away  forever  with  the 
discomfort  and  terrors  of  mal-de-mer.  Perhaps  the  most  vague  of 
all  suggestions,  propounded  in  all  seriousness,  is  that  seasickness 
is  due  to  a  "miasmatic  intoxication." 

In  this  manner  theory  followed  upon  theory  and  ''cure"  upon 
* '  cure. ' '  Vasomotor  stimulants  and  vasomotor  depressants ;  nerve 
excitants  and  nerve  sedatives ;  gastric  digestants  and  local  anjps- 
thetics — all  have  been  tried  only  to  be  discarded. 

With  the  discovery  of  the  physiolog>^  of  the  kinetic-static  laby- 
rinth and  a  study  of  the  phenomena  attendant  upon  the  stimulation 


36  EQUILIBRIUM  AND  VERTIGO 

of  this  organ,  the  true  etiolog}^  of  seasickness  at  hist  appeared. 
Many  authors,  among  them  Neumann,  Barany,  Ruttin,  Spira, 
Champeaux,  Trotsenburg,  Minor,  Savory  and  Barnett,  have  writ- 
ten excellent  scientific  and  reasonable  treatises  on  this  subject,  so 
that  it  is  rather  surprising  that  a  knowledge  of  the  etiology  of 
this  condition  is  not  universal;  but  as  Barany  very  clearly  points 
out,  the  present  chaotic  views  among  not  only  the  laity  but  even 
the  medical  profession  in  regard  to  the  nature  and  causation  of 
seasickness  must  be  ascribed  to  the  undeniable  fact  that  the  mechan- 
ism of  the  internal  ear  is  not  yet  generally  understood  and 
appreciated. 

The  symptoms  of  mal-de-mer  as  observed  and  described  by 
many  authors  are  fairly  constant.  There  is  first  noticed  a  more 
or  less  marked  dizziness  which  may  persist  for  a  considerable  time 
without  any  other  symptom.  Accompanying  this  vertiginous  feel- 
ing is  a  staggering  gait  when  motion  is  attempted.  The  early 
warm  flushing  of  the  face  becomes  quickly  replaced  by  a  feeling 
of  intense  chilliness  accompanied  by  pallor  and  cool  clammy  skin 
with  profuse  perspiration.  Nausea  makes  its  appearance  early 
but  is  not  quickly  followed  by  vomiting ;  when  the  vomiting  finally 
does  appear  there  is  occasionally  a  marked  feeling  of  relief  and 
with  some  individuals  the  attack  ceases  there  and  then.  This. 
however,  is  the  exception ;  as  a  rule  the  respite  is  of  but  short  dura- 
tion and  the  nausea  and  other  disagreeable  symptoms  soon  recur. 
The  vomiting  is  particularly  distressing;  continuous  and  painful 
retchings  continue  until  nothing  is  brought  forth  but  greenish 
bile-stained  mucus.  Some  patients  practically  go  into  a  collapse 
and  remain  in  a  state  of  shock  as  long  as  the  voyage  lasts,  while 
others  have  var^dng  intervals  of  comparative  comfort. 

It  is  now  universally  agreed  that  these  symptoms  are  brought 
on  by  the  movements  of  the  ship.  "When  attempting  to  determine 
just  how  these  movements  produce  the  enumerated  symptoms, 
anyone  w^ho  has  had  experience  in  testing  the  vestibular  portion  of 
the  internal  ear  cannot  help  but  be  struck  by  the  similarity  of 
symptoms  that  make  their  appearance  in  individuals  who  are 
turned  in  a  revolving-chair.    Such  turning  may  produce  the  iden- 


THE  P:AR  and  seasickness  37 

tical  symptom-complex  produced  by  the  same  cause — movement 
of  the  body.  In  the  one  instance  the  movement  is  produced  by 
the  tossing  of  the  ship ;  in  the  other  it  is  produced  by  being  turned 
in  a  chair.  We  know  that  being  revolved  in  a  chair  stimulates 
the  hair-cells  in  the  semicircular  canals  by  producing  a  movement 
of  the  lymph  within  the  canals.  At  the  outset,  therefore,  it  is  fair 
to  assume  that  those  vague  symptoms  known  as  mal-de-mer  are 
produced  in  the  same  way.  Furthermore,  if  this  assumption  be 
correct,  any  agency  which  induces  movement  of  the  lymph  within 
the  semicircular  canals  should  produce  the  same  symptoms.  Clini- 
cal experience  tells  us  that  this  is  true ;  douching  the  ear  with  either 
cold  or  hot  water  produces  the  same  train  of  symptoms.  Chilling 
the  outer  portion  of  the  capsule  of  the  internal  ear  by  douching 
with  cold  water  causes  a  downward  flow  of  the  endolymph,  whereas 
hot  water  causes  the  endoljmiph  to  rise.  Continued  douching  with 
cold  or  hot  water  inevitably  causes  any  normal  individual  to  be 
violently  * 'seasick."  With  these  thoughts  in  mind,  Kuttin  con- 
ducted the  following  experiment  upon  himself:  he  purposely  went 
out  to  sea  in  order  to  make  himself  seasick  and  when  in  that  con- 
dition he  had  both  of  his  ears  douched  simultaneously  by  means 
of  a  double  irrigator  devised  for  the  purpose.  The  seasickness 
disappeared  while  his  ears  were  being  douched,  but  unfortunately 
immediately  returned  after  the  douching  was  stopped.  The  power- 
ful effect  of  the  douching  had  caused  a  continuous  flow  of  the 
endohTnph  in  one  direction  and  for  the  time  being  made  it  im- 
possible for  his  internal  ears  to  detect  the  varied  movements 
of  the  ship. 

Very  few  individuals  are  exempt  from  seasickness :  women  are 
more  susceptible  than  men,  little  children  are  very  little  affected 
and  infants  are  immune.  It  is  striking  to  note  that  artificial  stimu- 
lation of  the  internal  ear,  either  by  turning  or  douching,  produces 
a  more  marked  effect  in  women  than  in  men,  verj^  little  effect  in 
little  children  and  no  effect  in  infants.  We  have  never  seen  vomit- 
ing result  from  douching  an  infant's  ear,  no  matter  how  long 
the  douching  was  continued.  The  violence  of  response  to  the  move- 
ment of  the  lymph  within  the  internal  ear,  whether  due  to  the 


38  EQUILIBRIUM  AND  VERTIGO 

tossing  of  the  ship  or  to  turning  and  douching,  is  in  direct  pro- 
portion to  the  degree  of  activity  of  this  organ.  The  vestibuhir 
mechanism  of  an  infant  is  not  yet  fully  developed  and  it  is  for  this 
reason  that  the  infant  is  immune  to  seasickness. 

Further  analogies  between  the  movement  of  the  ship  and  the 
result  of  artificial  stimulation  of  the  ear  are  brought  out  by 
Barany.^  In  both  instances  the  symptoms  subside  with  the  removal 
of  the  cause — the  docking  of  the  ship  in  the  one  case  and  a  cessa- 
tion of  labyrinthine  stimulation  in  the  other.  Alteration  of  the 
position  of  the  head  atTects  the  intensity  of  the  symptoms  in  both 
instances.  Nervous  or  high-strung  individuals  are  more  suscep- 
tible in  both  instances.  Individuals  acquire  a  tolerance  to  the 
movement  of  the  ship  so  that  they  gradually  lose  their  suscepti- 
bility to  seasickness ;  in  the  same  way  a  tolerance  is  induced  for 
the  tests  of  the  internal  ear  by  repeating  them  a  number  of  times. 
An  individual  who  cannot  be  nauseated  by  repeated  examinations 
of  the  vestibular  apparatus  cannot  be  made  seasick.  This  fact  has 
been  repeatedly  borne  out  in  our  experience.  Furthermore,  if  a 
certain  plane  of  movement  of  the  ship  is  found  to  affect  an  indi- 
vidual more  than  any  other  it  will  be  found  that  the  partic- 
ular fonn  of  vestibular  stimulation  which  imitates  the  same  move- 
ment will  also  affect  the  individual  more  than  a  movement  in 
another  plane. 

Any  physician  who  has  been  violently  seasick  and  has  ex- 
perienced the  sense  of  utter  annihilation,  with  violent  nausea  and 
vomiting,  diarrhcea  and  perspiration,  immediately  recognizes  that 
these  symptoms  are  identical  with  phenomena  seen  in  cases  of 
pathological  conditions  of  the  internal  ear,  such  as  the  various 
forms  of  labyrinthitis — the  so-called  "Meniere's  disease."  Here 
then  we  have  clinical  evidence  of  the  similarity  between  seasick- 
ness and  an  internal  ear-disturbance. 

All  these  points  of  resemblance  seem  to  point  to  mal-de-mer  as 
being  unquestionably  an  ear-phenomenon.  This  is  finally  and 
definitely  ])roved  by  the  observations  of  James  and  Kreidl.     The 

•  Seekranklieit,    Hanflbucli    der   Neurologic,    1014. 


THE  EAR  AND  SEASICKNESS  S9 

former  noted  that  deaf  mutes  could  not  be  made  seasick  under  any 
circumstances.  With  this  in  mind,  Kreidl  experimented  upon  ani- 
mals which  he  rocked  or  revolved  upon  a  mechanical  platform 
until  they  became  seasick.  He  afterwards  operated  upon  these 
animals  and  severed  their  VIII  Nerves.  After  they  had  recov- 
ered, he  repeated  the  same  experiment  and  was  unable  to  make 
them  vomit  even  by  the  most  violent  movements. 

Seasickness  therefore  is  an  ear-phenomenon.  We  now  con- 
sider the  mechanism  that  produces  this  phenomenon.  The  train 
of  symptoms  known  as  mal-de-mer  is  the  same  as  that  seen  after 
prolong-ed  and  violent  stimulation  of  the  ears ;  the  rolling  and 
pitching  movements  of  the  ship  constitute  the  cause  of  the  ear- 
stimulation.  To  be  sure,  the  ear  of  itself  does  not  produce  nausea 
or  vomiting  and  the  other  symptoms ;  these  manifestations  are 
brought  on  by  a  disturbance  of  the  central  nervous  system.  The 
equilibratory  end-organ  consists  of  two  tiny  sacs,  the  saccule  and 
utricle,  and  three  minute  tubes,  the  semicircular  canals ;  these  sacs 
and  tubes  are  so  designed  as  to  take  cognizance  of  every  conceiv- 
able movement  of  the  body.  There  are  two  of  these  organs,  one  on 
each  side  of  the  head,  each  one  continually  sending  out  a  flow  of 
tonic  impulses  to  various  parts  of  the  central  nervous  system 
and  also  to  the  musculature  of  the  entire  body.  Movement  of 
the  lymph  in  these  sacs  or  tubes  in  one  direction  stimulates  one 
group  of  hair-cells,  producing  certain  phenomena ;  movement  in 
a  reverse  direction  affects  different  hair-cells  in  the  end-organ 
and  results  in  different  phenomena.  This  is  made  possible  because 
of  different  nerve-pathways  connecting  the  different  hair-cells  with 
individual  and  separate  central  nuclei.  Some  of  these  nerve-paths 
have  been  actually  traced  from  the  ear  to  the  various  nuclei  in 
the  brain-stem  and  cerebellum.  Ordinary  movements  of  the  body 
produce  relatively  different  movements  of  the  endolymph  in  the 
semicircular  canals  on  both  sides,  but  there  is  no  confusion  be- 
cause the  brain,  through  countless  repetitions,  has  learned  to  inter- 
pret the  significance  of  all  these  movements.  Experiments  made 
on  individuals  in  turning-chairs,  swings,  or  in  rapidly-moving  ele- 
vators, show  that  a  continuous  definite  stimulation  of  one  or  more 


40  EQUILIBRIUM  AND  VERTIGO 

semicircular  canals,  produced  by  an  uninterrupted  flow  of  endo- 
l}inph,  is  usually  unaccompanied  by  any  unpleasantness;  disturb- 
ances occur  as  soon  as  there  are  reversals  of  the  relation  between 
the  moving  endolymph  and  the  hair-cells,  such  as  happen  when 
there  are  repeated  cessations  in  the  stimulation,  especially  if  such 
stops  and  starts  are  carried  out  in  quick  succession.  The  same 
is  true  when  the  endolymph  is  set  in  motion  by  douching  the  ear. 
If  the  right  ear  with  the  head  back  is  douched  with  cold  water, 
a  current  is  created  in  a  downward  direction  to  the  right;  if  the 
head  is  then  quickly  put  120°  forward,  the  current  of  the  endo- 
lymph is  reversed  to  the  left.  Putting  the  head  back  again,  again 
reverses  the  current.  Now  an  individual  may  not  be  at  all  alTected 
by  having  his  ear  douched  with  the  head  back  60°,  provided  it 
remain  in  that  position  as  long  as  the  stimulation  lasts.  If,  how- 
ever, the  position  of  the  head  be  changed  a  number  of  times,  the 
symptoms  of  seasickness  invariably  appear.  On  board  a  vessel 
we  unfortunately  have  just  such  a  state  of  affairs,  in  which  the 
complexity  of  movement  is  forever  changing  the  direction  of  the 
endoljmiph-current  in  the  semicircular  canals,  creating  havoc  with 
the  nerve-centres. 

The  state  of  brain-confusion  and  lack  of  interpretation  of  these 
impulses  does  not  last  forever,  and  after  a  varying  length  of  time, 
longer  with  some  individuals  and  shorter  with  others,  a  readjust- 
ment occurs.  The  brain  learns  the  meaning  of  all  these  stimuli, 
and  an  immunity  from  seasickness  results.  Such  an  immunity  is 
not  permanent  and  consists  only  of  an  exemption  from  the  malady 
under  conditions  similar  to  those  to  which  the  individual  had  be- 
come accustomed;  one  may  become  immune  to  seasickness  when 
aboard  a  large  vessel  sailing  on  the  ocean,  and  yet  when  embark- 
ing on  a  smaller  ship,  on  a  land-locked  sea,  the  movements  he  is 
then  subjected  to  are  quite  different  from  those  to  which  lie  had 
become  accustomed,  and  seasickness  may  again  result. 

The  mechanism  of  vomiting  consists  chiefly  of  motor  impulses 
through  the  vagus  and  phrenic  nerves.  The  nausea  is  an  entirely 
different  phenomenon,  and  consists  of  a  cerebral  interpretation 
of  the  unusual  stimuli.     Cumulative  nausea  may  produce  vomiting 


THE  EAR  AND  SEASICKNESS  41 

by  a  motor  impulse  from  the  cerebral  cortex  to  the  nuclei  of  the 
vagus  and  phrenic  nerves.    This  is  apparently  the  usual  sequence 
seen  in  seasickness ;  an  attack  almost  always  begins  with  a  vague 
unpleasantness  which  gradually  develops   into  a  nausea   which 
increases  in  severity  little  by  little  until  suddenly  projectile  vomit- 
ing occurs — as  the  result  apparently  of  the  cumulative  nausea. 
At  first  glance  it  w^ould  appear  that  the  vomiting  is  necessarily  the 
result  of  cerebral  impulses;  six  clinical  cases  in  our  experience, 
however,  show  that  cerebral  impulses  are  not  necessary  for  the 
stimulation  of  the  vagus  and  phrenic  nerves  and  that  there  must 
be  not  only  direct  pathways  between  the  ear  and  the  vagus  and 
phrenic  nuclei,  but  also  that  along  these  pathways  alone  stimuli 
may  produce  projectile  vomiting  entirely  dissociated  with  any 
cerebral  phenomena.     In  these  six  cases  because  of  lesions  high 
up  in  the  brain-stem,  stimulation  of  the  ears  failed  to  produce 
the  normal  responses;  prolonged  stimulation  produced  no  nystag- 
mus, no  vertigo,  no  past-pointing  and  no  falling — there  was  no 
nausea  and  the  patient  in  fact  asserted,  in  each  of  these  six  cases, 
that  he  did  not  in  any  way  **feel  different" — and  yet  suddenly 
violent  projectile  vomiting  occurred.     This  phenomenon  makes  it 
evident  that  there  is  a  low^er  direct  reflex  pathway  between  the 
semicircular  canals  and  the  nuclei  of  the  vagus  and  phrenic  nerves. 
It  is  very  easy  to  conceive  the  probable  course  of  these  pathways. 
Certain  vestibular  fibres  are  known  to  enter  the  posterior  longi- 
tudinal bundle,  which  in  turn  is  directly  connected  with  the  vagus 
nucleus ;  this  is  the  probable  anatomical  pathway  from  the  ear 
•to  the  Xth  nucleus.     Other  vestibular  fibres  after  entering  the 
medulla  oblongata  are  known  to  descend  to  the  motor  cells  of  the 
anterior  horns  of  the  s]Mnal  cord ;  the  phrenic  nerve  has  its  origin 
in  the  cells  of  the  anterior  horns  of  the  spinal  cord  at  the  second, 
third   and    fourth    cervical   vertebrae.      It    is    very   easy    to    see, 
therefore,  how  impulses  from  the  ear  may  travel  directly  to  the 
phrenic  nerve. 

It  must  of  course  be  recognized  that  there  are  many  associated 
and  predisposing  factors  in  tlie  production  of  seasickness  apart 
from  the  actual  movement  of  the  endolymph  within  the  semicircular 


42  EQUILIBRIUM  AND  VERTIGO 

canals.  Impressions  received  through  other  special  senses  may 
play  a  certain  part.  It  is  a  fact  of  common  knowledge  that  the 
presence  of  certain  odors  exert  a  definite  influence  in  increasing 
the  nausea.  Many  individuals  feel  that  they  could  have  weathered 
a  trip  in  fair  comfort  if  it  had  not  been  for  certain  odors,  such 
as  the  smell  of  food,  particularly  "greasy"  food,  such  as  i)ork 
fat,  or  the  so-called  "ship's  odors."  In  a  similar  way  visual  im- 
pressions of  the  movement  of  the  waves  or  of  the  line  of  the  hori- 
zon, or  the  mere  sight  of  other  people  suffering  from  seasickne.-^s, 
or  looking  at  the  vomitus  from  another  sufferer,  may  bring  on  an 
attack.  These  olfactory  and  visual  impulses  as  a  rule  merely  con- 
stitute the  "last  straw"  in  overcoming  the  cerebral  attempt  to 
keep  from  vomiting,  by  increasing  the  nausea  through  the  un- 
pleasant odors  or  visual  impressions.  Cases  are  known,  however, 
in  which  the  mere  sight  of  a  ship  at  her  moorings  has  brought  on 
nausea  and  vomiting.  Mere  fear  of  the  malady  itself  is  at  times 
a  very  potent  factor ;  such  a  psychic  state  no  doubt  increases  the 
irritability  of  the  nervous  mechanism.  The  essential  mechanism 
of  seasickness,  however,  is  that  movement  of  the  endolymph  within 
the  internal  ears  produces  nausea  by  means  of  impulses  from  the 
ears  to  the  cerebral  cortex,  and  produces  vomiting  not  only  as  a 
secondary  response  to  the  nausea  through  cerebral  impulses  to 
the  vagus  and  phrenic  nerves,  but  also  by  direct  impulses  from 
the  ears  to  the  nerves  whose  hyperactivity  produces  the  actual 
vomiting. 

Barany  has  classified  the  various  movements  of  the  ship  as 
occurring  in  certain  planes.  Wlien  the  passenger  is,  standing 
erect,  any  movement  of  the  ship  in  the  horizontal  plane  affects  his 
horizontal  semicircular  canals,  and  produces  no  unpleasantness. 
Unfortunately  this  movement  of  the  ship  is  very  rarely  seen.  The 
rolling  of  the  ship  from  side  to  side  affects  his  vertical  semicircular 
canals  (if  he  be  facing  bow  or  stern)  in  the  frontal  plane;  this  is 
distinctly  unpleasant,  and  if  under  these  circumstances  the  indi- 
vidual will  lie  down  in  the  long  axis  of  tlie  ship,  from  stem  to 
stern,  the  rolling  movement  will  then  affect  the  horizontal  canals 
and  relieve  the  unpleasantness.     If  the  ship  is  pitching  fore  and 


THE  EAR  AND  SEASICKNESS  43 

aft,  and  the  passenger  is  standing  upright,  facing  the  bow  or 
stern,  his  vertical  semicircular  canals  are  influenced  in  the  sagittal 
plane ;  if  he  then  lies  down  in  a  plane  across  the  ship,  the  pitching 
movement  will  then  aifect  his  horizontal  canals  and  thus  relieve 
the  unpleasantness.  Similarly  when  the  individual  is  standings 
the  up  and  down,  rising  and  falling  movement  of  the  ship  will  aifect 
him  unpleasantly,  and  this  maj^  also  be  relieved  by  lying  down. 
Very  frequently  the  effect  of  seasickness  can  be  greatly  ameliorated 
by  following  out  these  simple  measures ;  it  is  interesting  to  note 
that  observations  made  of  seasick  people  show  that  they  intui- 
tively assume  the  above  positions.  It  is  also  clinically  true  that 
most  people  ' '  feel  better  when  they  lie  down. ' '  Testing  individuals 
in  the  turning-chair  corroborates  these  facts;  turning  with  the 
head  upright,  stimulating  the  horizontal  canals  is  not  unpleasant, 
but  turning  with  the  head  forward  or  backward,  stimulating  the 
vertical  canals  in  the  frontal  plane,  or  turning  with  the  head  in- 
clined toward  the  shoulder,  stimulating  the  vertical  canals  in  the 
sagittal  plane,  is  invariablv  umileasnnt.  Naturally  on  board  ship 
we  are  seldom  dealing  with  movements  in  only  one  plane,  and  it  is 
the  combination  of  two  or  more  planes  of  movement  that  renders  it 
impossible  to  adapt  one's  self  to  so  many  varied  movements. 

THE   QUESTION    OF   PREVENTION    AND   TREATMENT    OF   SEASICKNESS 

This  much  discussed  subject  is  in  one  sense  the  most  unique 
in  the  whole  field  of  therapeutics,  in  that  we  are  dealing  with  a 
sickness  which  is  not  a  sickness  in  the  true  sense  of  the  word.  It  is 
a  normal  reaction  in  a  normal  mechanism.  Seasickness  is  of 
course  a  misnomer;  it  is  no  s^nse  pathologic  and  is  not  due 
to  "What  I  had  for  breakfast "*^or  "Because  1  am  in  such  a  run- 
down condition."  Such  states  to  be  sure  may  produce  a  nervous 
irritability,  Avhicli  would  predispose  the  individual  to  seasickness; 
but  the  fundamental  cause  itself— varied  movements  of  the  endo- 
lymph  and  the  inability  of  the  brain  either  to  interpret  or  disre- 
gard them — is  purely  physiologic.  Here  lies  the  difficulty  in 
prevention  and  treatment.  It  is  obviously  impossible  to  prevent 
the  movement  of  the  endolymph.     We  are  confronted  with  this 


44  EQUILIBRIUM  AND  VERTIGO 

physiologic  phenomenon  resulting  from  an  extraordinary  stimu- 
lation in  a  normal  organ  by  perfectly  ])hysiologic  means.  With 
the  removal  of  this  stimulation  in  fact  the  indisposition  promptly 
disappears.  The  fact  remains,  however,  that  the  symptoms  are 
most  distressing  and  any  means  toward  their  amelioration  should 
receive  careful  thought. 

With  the  true. etiology  of  the  condition  in  mind,  the  problem  pre- 
sented is  to  tind  means  of  lessening  the  irritability  either  of  the 
end-organs  within  the  labyrinth,  or  the  conducting  nerve  paths,  or 
of  the  nuclei  of  the  vagus  and  phrenic  nerves.  If  there  were,  to 
be  sure,  some  specific  drug  that  could  temporarily  abolish  the 
function  of  the  internal  ear  or  VIII  Nerve,  seasickness  would  be 
completely  *' cured";  unfortunately  the  pharmacopoeia  has  no  drug 
with  such  a  selective  action,  and  even  if  there  were  such  a  drug,  the 
individual  would  probably  be  stone-deaf  throughout  the  voyage. 
We  are  compelled  to  rely  on  the  cautious  administration  of  those 
remedies  which  lessen  general  nervous  irritability,  and  in  this 
way  also  influence  the  nervous  mechanism  in  question.  The  bro- 
mides are  the  most  valuable  of  all  remedies  for  the  prevention 
and  amelioration  of  seasickness.  The  strontium,  ammonium,  sodium 
and  potassium  salts,  singly  or  in  combination,  may  be  employed; 
strontium  salt  is  preferable  as  it  is  the  least  irritating  to  the 
stomach.  It  should  be  administered  in  moderate  doses,  such  as 
15  grains  three  times  daily,  beginning  one  week  prior  to  the  sailing 
and  continued  throughout  the  entire  voyage.  Other  nerve  seda- 
tives, especially  the  derivations  of  opium,  are  also  of  distinct  value. 

In  a  general  way  it  may  be  said  that  all  measures  directed 
toward  the  elimination  of  nervousness,  fear  and  conditions  con- 
ducive to  lowering  the  vitality  generally,  would  in  a  measure  tend 
to  prevent  seasickness.  The  gastro-intestinal  tract  should  be  put 
in  the  best  possible  condition,  A  brisk  cathartic  on  the  day  before 
sailing  and  a  very  light  assimilable  diet  prior  to  starting  on  the 
voyage  will  be  found  helpful.  Various  digestants,  such  as  pepsin 
and  peptenzyme,  have  appeared  to  have  a  beneficial  influence  in 
certain  cases,  but  it  must  be  recognized  that  they  are  useful  only 
in  so  far  as  they  aid  in  putting  the  gastro-intestinal  tract  in  as 
normal  a  condition  as  possible. 


THE  EAR  AND  SEASICKNESS  45 

Swinging  beds  or  chairs  have  been  suggested  and  have  been 
tried  out,  but  with  apparently  no  satisfactory  result.  If  they 
were  mechanically  feasible,  such  contrivances  would  rob  the  sea 
of  all  its  terrors ;  but  when  we  remember  the  complexity  of  move- 
ment to  which  a  ship  is  subjected,  we  can  readily  see  how  any 
swinging  chair  or  bed  to  eliminate  them  all  is  an  utter  impossibility. 

The  only  final  and  really  effective  means  of  preventing  seasick- 
ness is  to  get  the  individual  accustomed  to  the  extraordinary  laby- 
rinthine stimulation.  The  sailor  and  seasoned  traveler  accomplish 
this  by  the  many  repetitions  to  which  they  subject  themselves  in 
their  travels.  We  know,  however,  that  it  is  not  necessary  to  go 
out  to  sea  in  order  to  obtain  the  phenomena  of  labyrinthine  stimu- 
lation. This  can  be  easily  accomplished  in  the  turning-chair  and 
with  this  advantage,  that  the  amount  and  violence  of  such  stimula- 
tion is  under  the  perfect  control  of  the  doctor.  An  actual  attack  of 
seasickness  need  never  be  brought  on;  the  individual  can  either 
be  rotated  or  rocked,  or  have  the  ears  douched  up  to  the  limit  of 
toleration  and  the  stimulation  may  be  discontinued  with  the  first 
sign  of  discomfort.  Although  such  a  "treatment"  is  more  of  an 
academic  than  practical  interest,  it  is  perfectly  possible  to  accus- 
tom an  individual  to  increasing  "doses"  of  ear-stimulation,  and 
in  this  w^ay  to  cause  the  individual  to  develop  a  gradually  increas- 
ing tolerance.  Such  experimental  stimulation  should  enable  an 
individual  to  go  aboard  a  ship  for  the  first  time  practically  a 
seasoned  sailor.  This  theory  has  been  borne  out  in  our  clinical 
experience  in  that  repeated  stimulation  of  the  ears  in  the  same 
individual  has  invariably  shown  an  increasing  tolerance. 

Before  an  individual  goes  on  a  voyage  it  is  very  simple  by 
means  of  the  turning  and  douching  tests  to  determine  whether 
or  not  he  will  be  subject  to  seasickness ;  if  repeated  turnings  with 
the  head  in  different  positions  fails  to  produce  unpleasant  sensa- 
tions of  vertigo  or  nausea,  the  individual  may  be  assured  that  he 
has  nothing  to  fear  from  the  movement  of  the  waves.  If,  on  the 
other  hand,  the  turning  tests  prove  disagreeable,  the  individual  is 
verj''  apt  to  become  seasick  during  the  proposed  voyage.  In  other 
words,  it  is  a  very  simple  matter  to  determine  the  degree  of  func- 
tion and  stability  of  the  vestibular  apparatus  in  any  given  individ- 


46  EQUILIBRIUM  AND  VERTIGO 

ual.  If  the  patient  shows  a  high  degree  of  irritability  in  the 
responses  to  the  tests  of  the  turning-chair,  he  is  then  forewarned 
and  may  then  be  forearmed  by  appropriate  medication  before 
starting  on  the  voyage. 

The  treatment  of  an  actual  attack  of  mal-de-mef  resolves  itself 
into  the  symptomatic  treatment  of  the  phenomena  that  present 
themselves  at  the  time.  The  vomiting  and  retching  are  not  only 
extremely  distressing  but  may  even  result  fatally  from  hemor- 
rhage, especially  in  cases  in  which  there  is  present  a  pathologic 
condition  of  the  stomach.  Although  lavage  is  distinctly  helpful, 
it  is  well  to  remember  that  a  stomach  tube  is  not  xqyj  safe  in 
cases  of  violent  seasickness,  as  the  slightest  abrasion  of  the  gastric 
mucosa  may  be  attended  with  serious  consequences.  The  same 
result  can  be  accomplished  by  the  administration  of  copious 
draughts  of  some  alkaline  solution,  such  as  bicarbonate  of  soda  or 
of  a  solution  of  salt  and  water.  This  washing  of  the  stomach 
by  drinking  the  sodium  bicarbonate  or  salt  solution  helps  to  dis- 
solve the  rop3^  mucus  within  the  stomach  and  also  tends  to  relieve 
the  retching.  If  the  retching  is  very  violent  and  shows  no  tend- 
ency to  abate,  by  far  the  best  remedy  is  a  hypodermic  injection 
of  morphine,  gr.  i/o  to  be  repeated  if  necessary. 

The  character  of  the  ''sea"  prevailing  at  the  time  should  be 
stiiwiied  and  the  patient  placed  so  that  the  horizontal  semicircular 
oiaamals  are  the  ones  most  affected.  The  recumbent  posture  in  the 
G|)«a![:  air.  should  be  advised  if  possible. 

In  treating  the  collapse  which  is  usually  felt  after  an  attack, 
strychnine,  gr.  Vso,  or  atropin,  gr.  '/120,  one  or  both,  administered 
preferably  by  hypodermic  injection,  are  at  times  helpful.  As  a 
depressor  of  sensory  nerves  all  over  the  body  and  particularly  in 
the  intestinal  tract,  atropin  helps  to  eliminate  an  important  second- 
ary source  of  distress.  In  addition  to  this  the  stimulating  action 
of  atropin  on  the  medullary  centres  is  a  great  aid  in  re,gulating 
the  circulatory  disturbances  incidental  to  seasickness.  Alcohol 
produces  a  temporary  cerebral  exhilaration  so  that  for  the  time 
being  the  individual  "feels  better";  but  it  is  well  to  bear  in  mind 
that  alcohol  unquestionably  increases  the  irritability  of  the  nervous 
system,  and  this  is  just  the  very  thing  we  wish  to  avoid. 


CHAPTER  V 

THE  EAR  IN  SYPHILIS 

It  has  been  known  for  years  that  the  syphilitic  toxin  shows. 
a  marked  affinity  for  the  VIII  Nerve ;  actual  impairment  of  hear- 
ing, or  even  deafness,  has  been  observed  in  many  cases  very  early 
in  the  disease.  It  is  a  common  experience  among  otologists  to  find 
that  a  large  j)ercentage  of  syphilitics  in  the  various  stages  of  the 
disease,  show  an  impairment  of  the  labyrinth  and  VIII  Nerve. 
In  determining  the  degree  of  function  of  the  labyrinth  or  VIII 
Nerve,  however,  the  otologist  has  been  relying  upon  the  tuning- 
fork  tests  and  has  based  his  conclusions  upon  the  following 
findings : 

(1)  Bone-conduction  less  than  normal.  The  shank  of  a  vibrat- 
ing tuning-fork  is  held  against  the  head;  if  the  individual  ceases  to- 
hear  the  sound  before  the  tuning-fork  has  ceased  to  vibrate,  the 
bone-conduction  is  less  than  normal. 

(2)  Air-conduction  greater  than  bone-conduction,  in  the  pres- 
ence of  impaired  hearing.  This  suggests  a  nerve  involvement  be- 
cause if  the  impaired  hearing  were  due  to  a  middle  ear  lesion,  the 
air-conduction  would  be  less  than  the  bone-conduction. 

(3)  An  impairment  of  hearing  for  the  high  tones  is  g-©ne«iily 
regarded  as  indicating  an  impairment  of  the  general  ear  -or 
VIII  Nerve. 

These  tests  of  the  auditory  function,  to  be  sure,  should  not  be 
underestimated;  but  as  regards  precision  in  diagnosis,  which  is 
so  essential  in  this  matter  of  syphilis,  they  have  left  much  to  be- 
desired.  The  diminution  of  bone-conduction  is  of  itself  unreliable, 
not  only  because  it  depends  upon  the  statement  of  tlie  patient  as  to 
his  subjective  sensations,  but  also  because  even  in  the  presence 
of  cochlear  degeneration,  the  bone-conduction  may  not  be  dimin- 
ished because  of  an  associated  obstructive  lesion  of  the  middle  ear. 
It  is  perhaps  because  of  this  indefinitenes;s  that  the  use  of  ear- 
examinations  in  syphilis  has  not  come  into  general  use. 

47 


48  EQUILIBRIUM  AND  VERTIGO 

In  the  new  ear-tests,  however,  we  are  dealing  with  a  very  diifer- 
ent  matter;  these  tests  are  not  only  much  more  delicate,  but  consti- 
tute an  objective  measurement  of  the  degree  of  function  of  the 
VIII  Nerve.  We  are  not  dependent  on  mere  subjective  impressions 
of  the  patient.  It  is  a  very  different  matter  on  the  one  hand  to 
say,  "The  patient's  hearing  is  impaired,  yet  the  air-conduction  is 
less  than  the  bone-conduction  and  the  bone-conduction  is  less  than 
normal,"  and  on  the  other  hand  to  state,  ''Turning  to  the  right 
produced  a  horizontal  nystagmus  to  the  left  oi  11  seconds  of  poor 
amplitude."  Here  we  express  the  degree  of  function  of  the  VIII 
Nerve  with  mathematical  precision,  and  by  actually  observing  the 
movement  of  the  eyes. 

The  data  obtained  by  an  examination  of  the  labyrinth  are  of 
value  to  the  syphilologist  in  the  following  ways:  (I)  As  an  aid 
in  the  early  diagnosis  of  syphilis;  (2)  in  the  early  diagnosis  of 
syphilis  of  the  nervous  system;  (3)  in  the  early  recognition  of 
neural  recurrences;  (4)  in  estimating  therapeutic  activity  and 
efficiency;  (5)  in  helping  to  determine  whether  a  case  of  syphilis 
is  cured. 

(1)  In  the  early  diagnosis  of  syphilis  the  method  par  excellence 
is  of  course  the  demonstration  of  the  spirochseta  pallida  in  the 
serum  obtained  from  the  suspected  initial  lesion.  This  examina- 
tion requires  only  the  ordinary  microscope  with  its  oil  immersion 
lens,  fitted  with  a  dark  field  condenser,  and  with  a  brilliant  source 
of  illumination.  The  demonstration  of  the  organism  within  the 
first  few  days  after  the  appearance  of  the  suspected  lesion  con- 
stitutes the  ideal  early  diagnosis  of  the  disease.  When,  however, 
for  one  reason  or  another,  as  so  frequently  happens,  such  a  demon- 
stration of  the  micro-organism  is  not  made,  the  clinician  nuist  rely 
for  his  diagiiosis  on  the  early  recognition  of  constitutional  involve- 
ment, either  by  the  Wassermann  test,  the  appearance  of  the  well- 
recognized  clinical  manifestations  of  secondary  syphilis,  or  by 
observing  deviations  from  the  normal  responses  to  stimulation  of 
the  ear.  The  ear  examination  can  be  useful  in  the  following  way: 
If  a  patient  presents  a  suspicious  initial  lesion  and  the  ear-tests 
on  the  eighth  or  tenth  day  show  a  nystagmus,  after  turning,  of 


THE  EAR  IN  SYPHILIS  49 

18  seconds  instead  of  the  normal  26  seconds,  syphilis  may  be  sus- 
pected. If  after  three  or  four  days  more,  the  after-turning  nys- 
tagmus lasts  only  14  seconds  and  a  few  days  later  only  12  or  10 
seconds,  the  diagnosis  of  syphilis  is  strongly  suggested.  To  be 
sure  diseases  other  than  syphilis  may  have  previously  caused  an 
VIII  Nerve  impairment,  and  naturally  all  diseases,  such  as  mumps, 
scarlet  fever,  diphtheria,  nephritis,  diabetes  and  gastro-intestinal 
intoxication  must  be  considered.  In  all  of  these  affections,  how- 
ever, the  impairment  has  been  produced  at  some  previous  time  and 
the  resulting  impairment  remains  constant  during  the  period  of  the 
repeated  tests.  A  progressive  impairment  from  day  to  day,  on 
the  other  hand,  gives  evidence  of  a  strong,  active  toxin.  This 
strongly  suggests  syphilis. 

The  Wassermann  reaction  was  justly  hailed  as  an  extraordinary 
aid  to  the  clinician,  and,  when  properly  performed,  it  is  theoreti- 
cally a  specific  diagnostic  method.  Unfortunately,  the  Wasser- 
mann reaction  is  not  absolute.  Clinical  experience  teaches  us  that 
the  Wassermann  reaction,  as  performed  by  various  laboratories, 
cannot  be  relied  upon  in  many  cases  to  make  the  diagnosis  of 
syphilis.  It  is  common  experience  to  find  cases  that  are  clinically 
undoubtedly  syphilitic,  and  which  also  improve  under  antisyphi- 
litic  treatment  which  are  repeatedly  negative  to  the  Wassermann 
test.  The  Wassermann  test  has  also  been  reported  positive  in 
many  cases  which  have  subsequently  been  proven  to  be  non-syphi- 
litic. It  is  therefore  evident  that  in  many  cases  we  must  rely  upon 
other  means  of  diagiiosis,  and  in  many  such  cases  the  tests  of  the 
VIII  Nerve  may  lead  to  valuable  conclusions  as  to  the  presence  of 
a  constitutional  infection,  especially  so  if  there  is  found  a  progres- 
sive impairment  in  the  responses  obtained  by  repeating  these 
tests  at  intervals  of  a  few  days. 

(2)  Although  it  will  require  years  of  investigation  to  deter- 
mine the  exact  status  of  the  usefulness  of  these  tests  in  the  early 
diagnosis  of  syphilis,  we  already  know  that  in  detecting  a  beginning 
involvement  of  the  central  nervous  system,  these  tests  are  of 
unquestionable  value.  It  is  generally  stated  that  the  nervous 
system  is  attacked  in  five  per  cent,  of  those  affected.     We  venture 


50  EQUILIBRIUM  AND  A  ERTIGO 

to  suggest,  in  the  light  of  our  experience  to  date,  that  probably 
this  percentage  is  much  higher,  and  that  many  cases  are  not 
recognized  because  there  is  no  obvious  involvement,  as  in  loco- 
motor ataxia,  facial  paralysis,  or  general  paresis.  The  analysis  of 
the  function  of  the  VIII  Nerve  and  of  the  intracranial  pathways 
from  the  VIII  Nerve  within  the  brain-stem,  cerebellum,  and  cere- 
brum, may,  in  certain  cases,  demonstrate  a  beginning  involvement 
of  the  nervous  system  several  years  before  it  could  be  detected 
by  any  other  method. 

The  importance  of  the  early  recognition  of  cerebro-spinal  syph- 
ilis cannot  be  too  strongly  emphasized,  as  only  by  the  early  recog- 
nition and  appropriate  treatment  will  the  late  and  incurable 
manifestations  of  syphilis  of  the  nervous  system  be  avoided.  There 
is  both  experimental  and  clinical  evidence  to  show  that  certain  types 
of  spirochaeta  pallida  have  a  special  affinity  for  nerve  tissue  and 
infections  with  this  type  of  spirochsBta  pallida  are  not  so  apt  to 
produce  the  characteristic  cutaneous  lesions  of  secondary,  and  par- 
ticularly tertiary,  syphilis.  Spirochaeta  pallidae  recovered  from 
the  brain  and  cord  of  ataxic  and  paretic  patients  have  been  inocu- 
lated into  monkeys  and  have  produced  in  them  lesions  of  the 
nervous  system,  thus  showing  a  direct  affinity  of  this  type  of  spiro- 
chaeta pallida  for  nerve  tissue.  Clinically,  we  note  frequently  a 
negative  history  of  chancre  and  secondary  eruption  in  patients 
suffering  with  paresis  and  locomotor  ataxia — diseases  of  unques- 
tioned syphilitic  etiology.  Many  such  patients  are  married,  have 
apparently  healthy  wives  and  children  and  vehemently  deny  the 
possibility  of  syphilitic  infection.  Furthermore,  it  is  unusual  to 
encounter  upon  such  patients  the  typical  scars  of  healed  tertiary 
syphilides.  Vice  versa,  patients  suffering  with  recurrent  cuta- 
neous tertiary  syphilides  rarely  become  victims  of  locomotor 
ataxia  or  paresis. 

The  diagnosis  of  cerebrospinal  syphilis  has  depended  either 
upon  the  Wassermann  test  of  the  spinal  fluid  or  the  appearance 
of  clinical  evidence  of  involvement  of  the  cerebrospinal  system. 
A  Wassermann  test  of  the  spinal  fluid  is  easily  made  after  the  fluid 
is  obtained,  and  although  this  is  usually  secured  without  difficulty 


THE  EAR  IN  SYPHILIS  51 

by  spinal  puncture,  it  is  advisable  that  the  patient  go  to  bed  for 
at  least  twenty-four  hours,  and  frequently  there  occur  disagreeable 
sequelje,  including  severe  headache,  nausea,  vomiting  and  pain, 
all  of  which  considerably  influence  the  patient  against  subsequent 
spinal  tappings.  Involvement  of  the  spinal  nerves,  manifested 
by  alterations  in  sensation  and  in  motion,  occurs  very  late  in  the 
course  of  the  disease,  and  is  therefore  worthless  in  the  early 
recognition  of  syphilis  of  the  nervous  system.  The  same  may 
be  said  of  the  paralyses  which  occur  in  the  distribution  of  the 
cranial  nerves,  such  as  the  oculo-motor,  the  abducens  and  the  facial. 
Changes  in  the  optic  nerve  also  occur  late  in  the  disease,  as  a  rule, 
and  therefore  are  of  little  value  in  the  early  diagnosis  of  this 
disease.  On  the  contrary,  the  VIII  Nerve,  because  of  its  extensive 
ramifications  and  its  apparent  greater  susceptibility  to  toxaemia, 
is  the  most  likely  of  all  the  parts  of  the  nervous  system  to  be 
affected,  at  least  to  some  extent,  by  this  infection.  Further,  such 
changes  are  easily  detected,  and  at  times  definitely  located,  by  a 
careful  analysis  of  the  responses  obtained  by  artificial  stimulation 
of  the  vestibular  portion  of  the  VIII  Nerve.  There  are  no  tests 
of  any  of  the  other  cranial  nerves  which  compare  in  delicacy  and 
accuracy  with  the  new  tests  of  the  VIII  Nerve. 

(3)  The  determination  of  neural  recurrences  presupposes  the 
previous  syphilitic  involvement  of  the  nervous  system  and  its 
relief  by  suitable  treatment.  After  the  clinical  signs  of  syphilis 
have  disappeared,  the  patient  enters  wliat  is  called  the  latent  stage 
of  syphilis,  and  the  physician  is  compelled  to  rely  upon  the  Was- 
sermann  reaction  and  periodic  clinical  examinations  as  a  guide 
to  further  treatment.  Clinical  experience  teaches  that  when,  as 
a  result  of  treatment,  all  evidence  of  syphilis  has  disappeared  and 
the  Wassermann  reaction  has  become  negative,  the  first  evidence 
of  recurrence  or  relapse  into  the  active  stage  is  detected  by  a  posi- 
tive blood-serum  Wassermann  test.  This  positive  reaction,  if 
disregarded,  generally  increases  in  intensity  and  ultimately  there 
occurs  a  clinical  relapse  which  is  frequently  of  a  serious  nature. 
The  same  condition  unquestionably  occurs  in  neural  recurrences, 
and  would  probably  be  manifested  in  the  same  manner  if  a  series 


o'-i 


EQUILIBRIUM  AND  VERTIGO 


of  Wassermann  tests  of  the  spinal  fluid  could  be  obtained  as  easily 
as  a  series  of  blood-serum  reactions.  If  tests  of  the  VIII  Nerve 
prove,  in  the  future,  as  valuable  an  index  of  central  nervous  in- 
volvement as  they  give  promise  to  be,  we  will  have  in  them  an 
excellent  guide  as  to  the  condition  of  the  nervous  system,  of  much 
simpler  application  than  Wassermann  tests  of  the  spinal  fluid. 
A  negative  blood-serum  Wassermann  cannot  be  relied  upon  to 
exclude  involvement  of  the  central  nervous  system,  and  many 
cases  of  Avell-defined  lesions  of  the  central  nervous  system  give  a 
positive  Wassermann  reaction  of  the  spinal  fluid  and  a  negative 
blood-serum  reaction.  It  therefore  follows  that  in  latent  syphilis 
the  condition  of  the  patient  should  be  determined  by  periodic  Was- 
sermann reactions  of  the  blood-serum,  by  repeated  tests  of  the 
VIII  Nerve,  and  by  Wassermann  examinations  of  the  cerebro- 
spinal fluid,  if  permitted. 

(4)  In  estimating  the  efficiency  of  treatment  in  cases  of  cerebro- 
spinal syphilis,  the  ear-tests  serve  a  definite  purpose.  In  the  exact 
measurement  of  the  degree  of  function  of  the  ear-mechanism,  we 
have  an  index  of  the  progress  and  extent  of  the  specific  involve- 
ment of  the  rest  of  the  central  nervous  system.  A  progressive 
impairment  in  the  responses  to  ear-stimulation  indicates  a  change 
for  the  worse;  on  the  other  hand,  a  progressive  improvement  in 
the  responses  to  the  ear-tests  suggests  a  change  for  the  better. 

(5)  Before  pronouncing  an  individual  cured  of  syphilis,  one 
cannot  be  too  careful  in  investigating  the  condition  of  the  central 
nervous  system.  The  syphilologist  is  constantly  called  upon  to 
state  whether  a  case  is  cured  or  not.  Many  factors  must  be  con- 
sidered— the  time  at  which  the  diagnosis  was  made,  the  promptness 
with  which  treatment  was  instituted,  the  type  of  treatment,  re- 
peated clinical  examinations  of  the  patient,  and  the  results  of  the 
Wassermann  tests  of  the  blood  and  spinal  fluid.  Here  again  the 
ear-tests  are  of  value,  by  providing  additional  information  as  to 
the  condition  of  the  central  nervous  svstem. 


CHAPTER  VI 

THE  EAR  AND  THE  NEUROLOGIST 

The  intimate  relation  of  the  ear  to  the  central  nervous  system 
makes  the  study  of  neuro-otology  of  especial  interest  to  the  neu- 
rologist. The  value  of  an  eye-examination  in  neurologic  cases  is 
now  universally  recognized.  The  study  of  the  eye-grounds,  the 
field  of  vision,  pupillary  reaction  to  light  and  accommodation  and 
the  degree  of  function  of  the  eye-muscles,  furnishes  valuable  infor- 
mation to  the  neurologist.  Based  on  the  opinion  of  the  neurologists 
and  ophthalmologists  most  acquainted  with  these  ear-tests,  it  would 
seem  safe  to  assert  that  of  the  two  methods  of  approach,  very 
much  more  definite  information  can,  as  a  rule,  be  had  from  the 
examination  of  the  vestibular  apparatus  than  from  an  eye-exam- 
ination. The  value  of  ear-examination  in  neurologic  cases  is  re- 
cognized in  Vienna  to  the  extent  that  no  examination  of  a  neurologic 
case  is  considered  complete  without  a  report  from  the  otologist 
as  to  the  condition  of  the  vestibular  apparatus. 

The  neurologist  is  not  only  concerned  with  the  general  problems 
of  equilibrium  which  have  already  been  presented,  but,  in  addi- 
tion, he  has,  in  these  ear-examinations,  a  ver^^  definite  help  in 
many  perplexing  diagnoses.  The  ear-tests  are  of  particular  value 
in  making  a  dilTerential  diagnosis  between  labyrinth  and  intra- 
cranial lesions  and  in  furnishing  additional  data  in  intracranial 
localization. 

It  is  well  known  that  nystagmus  and  vertigo,  with  loss  of  equili- 
bration, associated  perhaps  with  nausea  and  vomiting,  may  be 
produced  either  by  a  disturbance  of  the  internal  ear  or  by  an  intra- 
cranial lesion.  In  many  instances  the  sjanptoms  of  internal  ear 
disturbance  and  of  a  cerebellar  lesion  are  identical.  It  is  in  such 
a  differentiation  that  the  ear-tests  are  often  invaluable.  It  not 
rarely  happens  that  a  careful  neurologic  study  indicates  a  lesion 
of  the  cerebellum,  whereas  the  ear-examination,  by  giving  addi- 

53 


54  EQUILIBRIUM  AND  VERTIGO 

tional  data  to  the  neurologist,  demonstrates  conclusively  that  he 
is  dealing  with  a  lesion  of  the  labyrinth.  Cases  of  this  type  are 
discussed  on  pages  19,  308,  329,  336  and  4-23. 

A  differential  diagnosis  between  peripheral  and  central  lesions 
by  means  of  the  ear-tests  depends  on  certain  general  principles.  A 
peripheral  lesion,  of  the  labyrinth  or  VIII  Nerve,  is  suggested 
by  the  following : 

(1)  An  impairment  of  the  function  of  both  the  cochlear  and 
kinetic-static  labyrinth.  If,  for  example,  the  hearing  tests  show 
cochlear  deafness  and  the  tests  of  the  semicircular  canals  show 
that  their  function  is  also  impaired,  it  immediately  becomes  prob- 
able that  we  are  dealing  with  an  end-organ  lesion. 

(2)  The  history  or  presence  of  tinnitus;  the  absence  of  tinnitus 
does  not  necessarily  indicate  that  the  end-organ  is  not  involved, 
but  its  presence  is  very  suggestive  of  labyrinth  involvement. 

(3)  Proportionate  impairment  of  the  responses  from  the  hori- 
zontal canal  and  of  the  responses  from  the  vertical  canals.  If, 
for  example,  the  tests  show  that  the  horizontal  canal  retains  only 
one-half  of  its  normal  function  and  that  the  vertical  canals  simi- 
larly retain  only  one-half  of  their  normal  function,  a  lesion  of  the 
end-organ  itself  is  suggested. 

(4)  Proportionate  impairment  of  both  nystagmus  and  vertigo. 
If  the  horizontal  canal  produces  one-third  of  the  normal  nystagmus 
and  one-third  of  the  normal  vertigo,  it  is  suggested  that  the  lesion 
is  in  the  horizontal  canal  itself  or  in  the  fibres  from  the  canal 
within  the  VIII  Nerve;  if,  in  addition,  the  vertical  canals  produce 
one-third  of  the  normal  nystagmus  and  one-third  of  the  normal 
vertigo,  an  end-organ  lesion  is  strongly  suggested. 

In  a  word,  it  is  the  ''proportionate  impairment"  of  responses 
that  speaks  for  a  peripheral  lesion. 

A  crntral  lesion  is  suggested  by  the  following: 

(1)  A  normal  cochlea,  but  impaired  or  non-responsive  serai- 
circular  canals. 

(2)  Normal  responses  from  the  horizontal  canal,  Imt  absent 
responses  from  the  vertical  canals. 


THE  EAR  AND  THE  NEUROLOGIST  55 

(3)  Normal  responses  from  the  vertical  canals,  but  impaired 
responses  from  the  horizontal  canal. 

(4)  Normal  vertigo,  but  impaired  nystagmus  from  the  hori- 
zontal canal. 

(5)  Normal  nystagmus,  but  impaired  vertigo  from  the  hori- 
zontal canal. 

(6)  Normal  vertigo,  but  impaired  nystagmus  from  the  vertical 
canals. 

(7)  Normal  nystagmus,  but  impaired  vertigo  from  the  vertical 
canals. 

(8)  Normal  vertigo  and  normal  nystagmus  from  any  semicircu- 
lar canal,  but  impaired  past-pointing  in  any  direction  of  any  one 
extremity. 

(9)  Normal  vertigo  and  normal  nystagmus  from  any  semicir- 
cular canal,  but  an  impairment  or  absence  of  the  normal  falling. 

(10)  Spontaneous  vertical  nystagmus  is  pathognomonic  of  a 
central  lesion  and  is  indicative  of  involvement  of  the  brain-stem 
caused  either  by  infiltration  or  pressure.  A  lesion  of  the  laby- 
rinth may  produce  many  forms  of  spontaneous  nystagmus — hori- 
zontal, rotary,  oblique  or  a  mixed  nystagmus  of  the  various  types ; 
but  an  ear  lesion  can  never  produce  a  spontaneous  vertical  nystag- 
mus, either  upward  or  downw^ird. 

(11)  If  there  exists  a  spontaneous  nystagmus  to  the  right  and 
non-responsive  semicircular  canals  of  the  right  ear,  an  intra- 
cranial lesion  is  suggested.  The  non-responsive  labyri^i^.  if  the 
labyrinth  itself  alone  were  responsible,  would  produce  a  nystagmus 
to  the  left. 

(12)  A  spontaneous  nystagmus  of  increasing  intensity  or  of 
long  duration  is  indicative  of  a  central  lesion.  A  spontaneous 
nystagmus  due  to  a  lesion  of  the  labyrinth  shows  its  greatest  inten- 
sity at  the  onset  of  the  disease,  becomes  less  and  less  marked  and 
disappears  after  a  few  days. 

(13)  If  a  stimulation  of  any  semicircular  canal  produces  a 
** perverted"  or  "inverse"  nystagmus,  it  is  pathognomonic  of  a 
central  lesion  and  is  indicative  of  brain-stem  involvement.  Such 
phenomena  as  the  following  are  frequently   seen:  Douching  the 


56  EQUILIBRIUM  AND  VERTIGO 

right  ear  with  cold  water  with  the  head  back,  stimulating  the  right 
horizontal  canal,  should  produce. a  pure  horizontal  nystagmus  to 
the  left.  If  on  such  stimulation  there  occurs  a  vertical  nystagmus 
upward  or  downward,  a  rotary,  oblique  or  mixed  nystagmus,  it  may 
be  spoken  of  as  "perverted."  If  instead  of  a  horizontal  nystagmus 
to  the  left  there  is  produced  a  pure  horizontal  nystagmus  to  the 
right,  it  may  be  termed  an  "inverse"  nystagmus.  Neither  a  per- 
verted nor  an  inverse  nystagmus  can  possibly  be  produced  by  a 
lesion  of  the  labyrinth  or  VIII  Nerve;  a  peripheral  lesion  pro- 
duces a  poor  nystagmus  or  no  nystagmus  at  all,  but  an  absolutely 
false  response  of  necessity  demonstrates  a  central  lesion. 

(14)  If  ear-stimulation  j^roduces  a  conjugate  deviation  of  the 
eyes  instead  of  a  nystagmus,  it  is  pathognomonic  of  a  central 
lesion. 

The  above  outline  indicates  how  additional  data  may  be  fur- 
nished to  the  neurologist  by  the  ear-tests  in  determining  whether 
he  is  dealing  with  a  lesion  of  the  internal  ear  or  of  the  brain-stem 
or  cerebellum.  In  the  broader  field  of  intracranial  localization, 
examination  of  the  ear  and  of  the  vestibular  apparatus  is  also  of 
distinct  value.  The  particular  feature  of  the  ear-examination  is 
that  the  aurist  sends  in  a  stimulus  to  the  brain-centres,  and  then 
notes  the  responses  of  different  parts  of  the  body  to  this  stimulus. 
For  example,  by  stimulation  of  the  ear  there  results  a  nystagmus 
in  a  given  direction,  a  pointing  of  the  extremities  to  the  right  or 
to  the  left  as  the  case  may  be  and  a  falling  to  the  right,  to  the  left, 
forward  or  backward  as  the  case  may  be.  Now  if  the  ear  and 
these  nerve  paths  from  the  ear  are  intact,  all  the  normal  responses 
will  appear ;  if  there  is  a  failure  of  all  or  any  of  the  responses  it  is 
positive  evidence  of  an  interruption  along  that  particular  path  or 
paths  that  fail  to  bring  about  these  responses. 

In  order  to  utilize  the  knowledge  obtained  from  these  tests  it 
is  essential  to  have  in  mind  the  various  pathways  constituting  the 
vestibular  apparatus.  These  pathways  are  presented  in  detail  in 
Chapters  XIV,  XV,  and  XVI.  It  may  be  stated  at  this  point  in 
brief  that  the  pathways  from  the  horizontal  semicircular  canal  are 
different  after  entering  the  brain-stem  from  those  from  the  verti- 


THE  EAR  AND  THE  NEUROLOGIST  57 

cal  canals;  furthermore  that  each  set  of  tracts  divides  into  two 
separate  pathways ;  one  pathway,  the  vestibulo-ocnlar  tract,  is  re- 
sponsible for  the  eye  movement,  and  the  other  pathway,  the  ves- 
tibulo-cerebello-cerebral  tract,  conveys  the  impulses  from  the  ear  to 
the  cerebral  cortex,  producing  vertigo.  If  the  horizontal  canal 
fails  to  produce  both  nystagmus  and  vertigo  the  lesion  indicated 
is  at  a  point  before  the  division  of  the  horizontal  canal  fibres  into 
their  two  separate  pathways.  Further,  if  the  horizontal  canal 
produces  normal  vertigo  but  no  nystagmus  the  lesion  indicated  is 
of  the  vestibulo-ocular  tract  at  a  point  beyond  the  point  of  division 
into  the  two  paths.  If  the  horizontal  canal  produces  normal 
nystagmus  but  no  vertigo  the  lesion  indicated  is  at  a  point  along 
the  vestibulo-cerebello-cerebral  path  beyond  the  point  of  division 
into  the  two  pathways.  Similarly  if  the  vertical  canals  produce 
normal  vertigo  but  no  nystagmus  the  lesion  indicated  is  in  the 
vestibulo-ocular  tract  at  a  point  beyond  the  division  into  the  two 
paths.  If  the  vertical  canals  joroduce  normal  nystagmus  but  no 
vertigo,  the  lesion  indicated  is  at  a  point  along  the  vestibulo- 
cerebello-cerebral  path  beyond  the  point  of  division  into  the  two 
pathways.  A  more  detailed  analysis  of  this  kind  is  given  in 
Chapter  XXIII.  The  ear-tests  have  proved  themselves  surpris- 
ingly helpful  in  locating  lesions  in  the  cerebello-pontile  angle, 
medulla  oblongata,  pons,  cerebellar  peduncles,  cerebellum  and 
various  portions  of  the  cerebrum,  including  the  parietal  lobe,  the 
temporal  lobe  and  the  occipital  lobe. 

In  order  to  obtain  reliable  data  from  an  ear-examination,  it  is 
essential  that  the  technic  of  examination  should  be  accurate  and 
painstaking;  since  it  is  primarily  an  ear-examination,  the  otologist 
is  peculiarly  fitted  to  carry  out  such  examinations.  Although  one 
purpose  of  this  book  is  to  furnish  a  practical  guide  for  the  otologist 
in  undertaking  the  examination  of  patients,  it  is  also  offered  to 
the  neurologist  so  that  he,  on  his  part,  may  become  familiar  with 
the  ear  aspects  of  the  work,  in  order  to  realize  the  significance  of 
the  reactions  as  reported  to  him.  The  ear-examination  is  obviously 
not  for  the  purpose  of  making  a  neurologic  diagnosis;  it  merely 
gives  additional  information  by  a  series  of  refined  experiments, 


58  EQUILIBRIUM  AND  VERTIGO 

to  the  other  methods  at  the  command  of  the  neurologist.  To  be 
sure,  there  are  many  cases  in  which  the  neurologist,  without  the 
aid  of  the  ear,  eye,  blood,  or  other  examinations,  finds  no  diffi- 
culty in  arriving  at  a  satisfactory  diagnosis.  In  these  cases,  how- 
ever, it  is  of  course  useful  to  have  the  additional  evidence  from 
the  ear-tests  corroborating  his  neurologic  and  other  findings.  In 
addition,  it  not  infrequently  happens,  in  obscure  cases,  or  in  cases 
in  which  the  neurologic  data  are  meagre,  that  the  ear-tests  may 
be  the  only  means  of  furnishing  information  upon  which  a  diag- 
nosis can  be  made.  For  example,  an  apparently  strong,  vigorous 
man,  complaining  only  of  headache,  showed  on  examination,  that 
both  internal  ears  were  normal,  and  also  that  both  VIII  Nerves 
were  normal,  and  yet  the  vertical  semicircular  canals  of  both  ears, 
when  stimulated,  failed  to  produce  any  responses  whatever.  The 
horizontal  canals  produced  normal  nystagmus,  but  no  vertigo.  As 
the  labyrinths  and  VIII  Nerves  in  this  case  were  unquestionably 
normal,  the  non-appearance  of  the  normal  responses  to  stimulation 
could  be  accounted  for  only  by  an  interference  with  the  fibres  from 
the  labyrinth  within  the  brain-stem.  This  particular  phenomenon- 
complex  indicates  pressure  within  the  IV  Ventricle.  This  con- 
clusion was  recorded  with  considerable  misgiving  because  a  lesion 
within  the  IV  Ventricle  appeared  ridiculous,  in  view  of  the  man's 
apparent  health.  That  night  the  patient  was  rushed  to  the  hospital 
unconscious.  The  next  day  he  regained  consciousness,  but  com- 
plained of  agonizing  headache.  Examination  by  a  number  of  intern- 
ists and  neurologists  failed  to  give  any  clue  of  an  organic  lesion 
anywhere,  and  the  diagiiosis  of  hysteria  was  made.  Autopsy  three 
days  later  showed  abscess  in  the  IV  Ventricle.  It  is  in  such  cases 
as  this  that  the  ear-examination  is  of  the  utmost  importance,  as 
it  gives  data  absolutely  unobtainable  by  the  usual  neurologic  tests. 


CHAPTER  VII 

THE  EAR  AND  THE  SURGEON 

The  diagnosis  of  the  precise  location  of  lesions  within  the 
cranium  is  probably  the  most  difficult  task  with  which  the  surgeon 
is  confronted.  Fully  realizing  all  the  difficulties  in  these  cases, 
he  utilizes  every  modern  aid  in  diagnosis — the  laboratory,  the 
X-ray,  or  any  other  instruments  of  precision  that  may  be  available. 
For  many  years  the  ophthalmologist  has  been  of  great  help  to  the 
surgeon  in  his  intracranial  cases,  and  no  one  would  think  of  oper- 
ating on  such  a  case  without  first  having  the  ophthalmologist's 
report  as  to  his  findings.  The  previous  chapter  has  shown  how 
the  ear-tests  may  furnish  data  of  value  in  tlie  accurate  localization 
of  lesions  which  involve  any  of  the  vestibular  pathways,  as  well 
as  in  differentiating  between  labyrinth  and  intracranial  lesioiis. 
A  point  worthy  of  special  emphasis  is  that,  with  the  ajd  of  these 
tests,  he  is  frequently  enabled  to  determine  whether  a  lesion  is 
operable  or  inoperable.  Many  lesions  of  tlie  meduljjk.  oblongata, 
pons,  or  cerebellar  peduncles,  which  are  inoperable  by  the  very 
nature  of  their  location,  will  show  very"' pronf^unced  cerebellar 
symptoms,  and  not  infrequently  the  cej'e'belhim  is  explored,  in  such 
cases,  in  the  hope  of  finding  a  tumor  near  the  cortex,  and  removing 
it.  For  such  a  differentiation,  in  maity  cases,  no  method  can  equal 
the  accuracy  of  the  Barany  tests.  Ii,  after  turning  and  douching, 
there  appears  a  normal  past-pointing  of  both  extremities  in  both 
directions,  it  may  safely  be  assumed  that  the  cerebellum  itself  is 
intact.  This  cannot  be  regarded  as  absolutely  final,  but  is  much 
more  definite  than  any  other  known  method  for  determining  the 
integrity  of  the  cerebellum.  It  is  perfectly  conceivable  that  a  case 
showing  almost  normal  past-pointing  may  apparently  reveal  a 
lesion  when  a  cerebellar  decompression  is  done.  We  have  seen 
two  such  cases.  Here,  however,  it  should  be  explained  that  in  both 
these  instances  the  lesion  proved  to  be  a  cyst  which  grew  from 
the  brain-stem  and  extended  backwards  between  the   cerebellar 

59 


60  EQUILIBRIUM  AND  VERTIGO 

liemisplieres,  without,  however,  destroying  the  substance  of  the 
cerebellum  itself.  Such  cases  give  definite  neurologic  evidence  of 
a  cerebellar  lesion,  and  at  the  time  of  operation,  such  a  lesion  is 
apparently  discovered.  There  may  have  been  present  asynergy, 
manifested  by  hypermetry,  adiodokokinesis  and  tremor,  yet  these 
symptoms  or  phenomena  were  produced  by  involvement  of  the 
fibres  071  their  way  to  the  cerebellum,  or  by  pressure  upon  the 
cerebellum  itself.  If,  then,  the  ear-tests  demonstrate  normal  past- 
pointing,  it  is  strong  evidence  that  the  cerebellum  itself  is  not 
involved. 

Tumors  in  the  cerebello-pontile  angle  either  originate  from  one 
of  the  cranial  nerves  in  the  angle,  usually  the  VIII  Xerve,  or  have 
invaded  the  angle  secondarily  from  the  cerebellum  or  brain-stem. 
These  tumors  invading  the  angle  from  other  adjacent  structures 
also  usually  involve  the  VIII  Nerve.  Obviously  then  a  careful 
study  of  the  various  portions  of  the  VIII  Nerve  gives  direct  insight 
as  to  conditions  in  the  cerebello-pontile  angle.  In  addition,  in  our 
experience  the  ear-tests  have  usually  demonstrated  the  two  follow- 
ing phenomena,  in  cases  of  cerebello-pontile  angle  growth : 

(1)  An  absence  of  all  responses  from  the  vertical  canals  of  the 
ear  opposite  the  side  of  the  lesion.  Given  a  tumor  in  the  right  cere- 
bello-pontile angle,  the  usual  findings  are  as  follows :  The  right  ear 
gives  no  responses — the  cochlea  shows  absence  of  all  function  and 
the  horizontal  and  vertical  canals  fail  to  produce  any  nystagmus, 
vertigo,  past-pointing  or  falling.  The  left  ear  shows  unimpaired 
hearing  and  the  left  horizontal  canal  does  produce  nystagmus, 
vertigo,  past-pointing  and  falling.  The  left  vertical  canals,  how- 
ever, fail  to  produce  any  responses,  because  the  vertical  canals 
fibres  are  most  probably  impaired  because  of  pressure  upon  the 
pons  by  the  tumor  in  the  angle. 

(2)  '^Crossed  past-pointing."  This  phenomenon  consists  of 
persistent  past-pointing  of  both  upper  extremities  either  outward 
or  inward,  regardless  of  the  type  of  ear-stimulation  employed. 

If  ear-stimulation  produces  normal  nystagmus,  vertigo,  past- 
pointing  and  falling,  the  Barany  tests  are  of  unquestioned  value  in 
eliminating  lesions  in  the  posterior  fossa  and  brain-stem.    If  they 


THE  EAR  AND  THE  SURGEON  61 

rendered  no  other  service  than  this  it  would  be  sufficient  to  hail 
them  as  a  distinct  contribution  in  the  diagnosis  of  intracranial 
lesions.  In  addition  these  tests  may  prove  helpful  to  the  surgeon 
in  preventing  unnecessary  operations.  One  case,  given  in  detail 
in  Chapter  XXIII,  page  308,  case  number  2,  is  of  interest  in  this 
connection.  A  woman  appeared  to  have  a  tumor  of  the  right 
cerebellar  hemisphere.  This  diagnosis  w^as  confirmed  by  neuro- 
logic consultants  and  the  X-ray  report  stated  that  it  was  a  cyst  in 
the  right  cerebellar  hemisphere.  The  ear-tests  suggested  that  the 
cerebellum  was  uninvolved ;  operation  was  delayed  on  this  account 
and  eventually  was  found  to  be  unnecessary,  as  the  patient  steadily 
improved  and  was  discharged  from  the  hospital  apparently 
well  and  for  years  has  had  no  recurrence  of  her  symptoms. 
Her  cerebellar  s>Tnptoms  evidently  were  due  to  a  disturbance  in 
the  internal  ear. 

No  operation  upon  the  brain  should  be  undertaken  without  giv- 
ing the  patient  the  benefit  of  an  ear-examination.  ' 


CHAPTER  VIII 

THE  EAR  AND  THE  OPHTHALMOLOGIST 

The  intimate  relation  between  the  ear  and  the  eye  can  be  best 
appreciated  when  we  realize  that  the  ocular  mechanism  constantly 
depends  upon  stimuli  from  the  ear  for  precision  of  movement. 
Steadiness  of  fixation  is  dependent  to  a  large  extent  on  normally 
functionating  ears.  Tonic  impulses  from  the  right  ear  continually 
tend  to  draw  both  eyes  to  the  left.  This  is  definitely  proven  in 
that  a  sudden  loss  of  function  of  the  right  internal  ear  invariably 
results  in  a  deviation  of  the  eyes  to  the  right,  because  the  tonic 
impulses  tending  to  draw  the  eyes  to  the  left  is  impaired,  and  there 
is  a  resulting  niistagmus  to  the  left.  Similarly  sudden  loss  of  func- 
tion of  the  left  internal  ear  invariably  results  in  a  deviation  of  the 
eyes  to  the  left,  because  the  tonic  impulse  tending  to  draw  the 
eyes  to  the  right  is  impaired,  and  there  is  a  resulting  nystagmus 
to  the  right.  This  may  be  further  demonstrated  experimentally  by 
the  use  of  electricity.  In  applying  the  galvanic  current  to  the 
right  ear,  by  the  use  of  the  anode,  which  depresses  its  function, 
there  results  a  drawing  of  both  eyes  to  the  right  with  a  resulting 
nystagmus  to  the  left.  The  kathode,  stimulating  the  right  ear 
causes  a  drawing  of  both  eyes  to  the  left  with  a  resulting  nystagmus 
to  the  right.  These  diametrically  opposite  phenomena  can  be  pro- 
duced merely  by  reversal  of  the  current.  It  is  thus  shown  that 
ocular  equilibrium  in  the  same  sense  as  bodily  equilibrium  is  nor- 
nally  dependent  on  properly  functionating  ears.  Barthels,  in  fact, 
has  demonstrated  that  rabbits  probably  have  no  voluntary  con- 
trol of  the  ej^es  at  all  and  that  their  ocular  movements  depend 
entirely  upon  stimuli  from  the  internal  ears ;  section  of  the  VIII 
Nerves  produces  a  complete  loss  of  eye-movements. 

It  is  also  of  interest  to  the  ophthalmologist  that  artificial  stimu- 
lation of  the  ear  can  produce  ''to  order"  a  nystagmus  of  any  type, 
in  any  direction.  There  is  an  absolute  and  definite  relation  between 
the  canal  stimulated  and  the  type  of  nystagmus  produced.     The 


THE  EAR  AND  THE  OPHTHALMOLOGIST  63 

laws  governing  this  relation  are  simple  and  invariable.  If  we  wish 
to  produce  a  vertical  nystagmus  upward,  we  place  the  patient's 
head  over  toward  the  right  shoulder,  turn  him  to  the  left,  and 
there  appears  a  vertical  nystagmus  upward.  If  we  wish  a  rotary 
nystagmus  to  the  left,  we  douche  the  right  ear  with  head  upright 
with  cold  w^ater,  or  douche  the  left  ear  with  hot  water,  and  there 
is  produced  a  rotary  nystagmus  to  the  left.  These  examples  illus- 
trate this  marvelously  exact  ear-to-eye  mechanism  and  give  some 
conception  of  the  fixed  relationship  between  the  semicircular  canals 
and  the  eye-muscles.  The  ''fistula"  test  serves  as  another  illus- 
tration. If  there  is  caries  of  bone  in  the  outer  wall  of  the  laby- 
rinth producing  a  fistula  into  the  internal  ear,  or  for  that  matter, 
if  the  stapes  is  unduly  mobile  in  the  oval  window,  applying  a 
Politzer  bag  into  the  ear  aud  ]iroducing  pressure  or  suction,  causes 
the  eyes  to  dance  violently. 

These  tests  have  a  practical  application  in  the  study  of  ocular 
palsies  and  of  spontaneous  nystagmus. 

Ocular  Palsies 

In  the  study  of  ocular  palsies,  it  is  important  to  note  that  the 
ear-stimulation  is  much  stronger  than  the  voluntary  cerebral 
stimulus.  If  an  individual  is  unable  to  look  to  the  right  with  the 
right  eye,  the  question  arises  as  to  the  degree  of  involvement  of 
the  right  VI  Nerve.  If  ear-stimulation  causes  the  eye  to  move  out- 
ward it  is  evident  that  the  VI  Nerve  is  not  completely  destroyed. 
This  makes  a  refinement  in  the  determination  of  the  degree  of 
])aresis  and  to  that  extent  is  of  service  in  estimating  the  prognosis. 
In  this  case  in  which  the  patient  is  unable  to  look  to  the  right  with 
the  right  eye,  the  right  abducens  nerve  or  its  nucleus,  or  the  right- 
external  rectus  muscle  are  naturally  suspected.'^  Tp  utilize  the 
ear-tests  in  examining  this  mechanism  it  is  only  necessary  to  recall 
that  a  stimulation  of  one  or  the  other  horizontal  semicircular  canal 
can  produce  a  moverftent  oMhe  right  eye  outward.  The  horizontal 
canal  is  conne^Ted  by  nerve  paths  with  the  VI  Nucleus  and  with  that 
portion  of  the  III  Nucleus  which  controls  the  internal  rectus  mus- 
cle.   Appropriate  stimulation  is  therefore  applied,  such  as  turning 


64  EQUILIBRIUM  AND  VERTIGO 

the  patient  in  a  revolving-chair  to  the  right  with  the  head  30° 
forward,  or  donching  the  right  ear  with  head  back,  water  68°  F. 
or  douching  the  left  ear,  with  head  back,  60",  with  water  112°  F. 
All  these  tests  normally  w^ould  cause  both  eyes  to  be  drawn  to  the 
right.  In  many  cases  such  tests  wdll  demonstrate  that  the  patient's 
inability  to  look  to  the  right  when  asked  to  do  so  was  due  to  only 
a  partial  involvement  of  the  VI  Nerve  mechanism  because  when 
a  powerful  ear-stimulus  was  applied,  the  right  eye  did  actually 
move  to  the  right. 

Similarly,  if  the  patient  is  unable  to  look  to  the  left,  with  the 
left  eye,  those  tests  are  applied  to  the  ears  which  should  normally 
draw  the  eyes  to  the  left,  such  as  turning  to  the  left  with  the  head 
30°  forw^ard,  or  douching  the  right  ear  with  the  head  60°  back, 
with  water  112°  F.,  or  douching  the  left  ear  with  the  head  back 
60°,  with  water  68°  F. 

If  the  patient  is  unable  to  look  upward,  that  ear-stimulation  is 
applied  which  would  normally  cause  the  eyes  to  be  drawn  upward, 
such  as  turning  the  patient  to  the  right  with  the  head  inclined 
toward  the  right  shoulder,  or  turning  to  the  left  with  the  head 
inclined  toward  the  left  shoulder.  These  methods  illustrate  how 
the  ear-tests  can  determine  whether  any  given  portion  of  the  ocular 
muscle  mechanism  is  or  is  not  destroyed. 

Loss  of  conjugate  deviation  in  various  directions  should  always 
be  studied  by  means  of  the  ear-tests.  There  is  a  loss  of  voluntary 
control ;  the  patient  is  unable,  when  asked,  to  look  in  a  given 
direction  with  either  eye.  If  the  ear-stimulus  causes  the  eyes  to 
move  in  this  direction,  it  shows  without  question  that  there  are 
normal  pathways  from  the  ear  through  the  eye-muscle  nuclei  and 
through  the  nerves  of  the  eye-muscles  themselves — therefore,  the 
lesion  is  supranuclear. 

Spontaneous  Nystagmus 

Before  taking  up  the  value  of  ear-examinations  in  cases  of 
spontaneous  nystagnms,  it  must  be  pointed  out  that  until  recently 
our  knowledge  of  nystagmus  as  such  has  been  vague.  It  w^as 
known  to  occur  in  certain  eye-conditions,  was   considered   as   a 


THE  EAR  AND  THE  OPHTHALMOLOGIST  65 

symptom  of  certain  diseases  of  the  central  nervous  system  and  in 
an  indefinite  way  it  was  also  noted  that  at  times  nystagmus  resulted 
from  an  internal  ear  involvement.  The  new  ear-tests  have  thrown 
much  light  upon  this  subject. 

In  a  given  case  of  spontaneous  nystagmus,  the  first  problem  is 
the  determination  of  its  type.  Is  it  ocular  or  vestibular?  If  the 
oscillations  of  the  eye-balls  consist  simply  of  a  to-and-fro  roll, 
similar  to  the  swing  of  a  pendulum — that  is  the  movement  or  roll 
in  one  direction  is  just  as  large  and  just  as  rapid  as  in  the  other 
direction — then  it  is  of  an  ocular  type  and  suggests  some  local 
eye  disturbance.  It  may  be  due  to  any  condition  that  prevents 
the  rays  of  light  from  pursuing  an  uninterrupted  course  through 
the  various  ocular  media,  such  as  corneal  scars  or  anterior  polar 
cataract.  In  such  a  condition  the  nystagmus  is  apparently  the 
result  of  an  attempt  to  obtain  a  clear  unobstructed  view  for  fixa- 
tion^— to  ''look  around  the  obstacle,"  as  it  were.  Ocular  nystag- 
mus may  also  result  from  an  interference  with  the  proper  action 
of  the  rays  of  light  at  the  macula,  provided  that  the  lesion  occurred 
before  central  fixation  was  established. 

In  sharp  contrast,  if  the  movements  of  the  eyes  exhibit  a  definite 
rhythm — a  slow  movement  in  one  direction  followed  by  a  quick 
recoil  in  the  opposite  direction — the  nystagmus  is  of  a  ''vestibular 
type"  and  is  due  to  a  disturbance  of  the  ocular  nerve-mechanism 
and  not  to  a  lesion  in  the  eyes  themselves.  It  can  be  produced  by 
a  lesion  affecting  any  of  the  pathways  between  the  ear  and  the  eye- 
muscle  nuclei,  the  lesion  being  located  either  within  the  ear  or 
within  the  cranium.  Such  a  nystagmus  is  not  due  to  an  attempt 
to  accomplish  fixation  but  is  due  to  a  distufbance  within  either 
the  nuclei  themselves  or  through  impulses  from  the  ear  to  the  eyes 
w^hich  cause  the  eyes  to  deviate  to  one  side.  When  the  eyes  are 
thus  drawn  to  one  side,  impulses  from  the  cerebrum,  to  the  eye- 
muscle  nuclei  quickly  bring  the  eyes  back  in  the  opposite  direction. 
The  slow  component  of  the  nystagmus  is  caused  by  an  irritation, 
impairment  or  destruction  of  the  pathways  from  the  ear  to  the 
eye-muscle  nuclei,  whereas  the  quick  component  of  nystagmus 
results  from  the  attempt  of  the  cerebrum  to  correct  the  altered 
position  of  the  eyes. 


C6  EQUILIBRIUM  AND  VERTIGO 

The  cause  of  ocular  nystagmus  is  readily  determined  by  an  eye- 
examination,  but  it  is  in  those  cases  in  which  the  lesion  lies  not  so 
near  the  surface  that  the  ear-tests  are  absolutely  essential.  Re- 
cently there  were  two  babies,  both  showing  a  wild  oscillatory  nys- 
tagmus. Naturally  it  was  the  ophthalmologist  who  was  called  on 
to  determine  its  cause;  he  found  nothing  wrong  in  the  eyes  them- 
selves to  account  for  the  nystagmus.  The  ear-tests,  however, 
showed  a  striking  difference  between  the  two  cases.  On  one  we 
reported,  "The  ear-tests  suggest  an  irritation  of  the  vestibulo- 
ocular  tracts,  but  no  organic  impairment;  the  prognosis  is  good." 
The  child  had  a  perfect  recovery.  The  report  of  the  other  patient 
was,  "There  is  an  organic  block  of  the  vestibulo-ocular  tracts  of 
both  sides  in  the  brain-stem;  the  prognosis  is  bad."  This  patient 
died.  The  reasons  for  these  reports  were,  that  the  first  patient, 
on  ear-stimulation,  immediately  showed  a  change  of  the  oscillatory 
nystagmus  into  a  definite  rhythmic  pull.  The  ear-stimulation,  as 
it  were,  seized  both  eyes  and  caused  them  to  move  rhythmically 
in  the  proper  direction ;  evidently,  therefore,  there  was  no  organic 
block  of  the  pathways.  The  other  patient  continued  to  have  the 
oscillatory  nystagmus  which  was  entirely  unaffected  by  ear-stimu- 
lation, thus  showing  a  definite  organic  block  of  the  pathways  from 
both  ears  to  the  eyes. 

In  any  case  of  spontaneous  nystagmus  in  which  there  is  no 
obvious  ocular  lesion,  the  ear-tests  provide  a  means  of  approach 
in  determining  its  cause  or  the  site  of  the  lesion.  In  fact,  no  case 
of  nystagmus  can  now  be  considered  to  have  been  fully  studied  until 
the  ear-tests  are  made. 


CHAPTER  IX 
THE  INTERNAL  EAR  AND  THE  OTOLOGIST 

V^EKY  little  need  be  said  of  the  importance  or  uses  of  a  study 
of  the  cochlear  labyrinth  to  the  otologist,  but  those  otologists  who 
have  been  particularly  interested  in  a  study  of  the  kinetic-static 
labyrinth  feel  that  the  recent  advances  in  neuro-otology  have  a  prac- 
tical every-day  usefulness  to  the  otologist  that  is  not  yet  recognized. 
An  examination  of  the  internal  ear  is  certainly  incomplete  if  only 
one  portion  of  it  has  been  examined.  Surely  the  kinetic-static 
portion  of  the  internal  ear  should  receive  equal  consideration  with 
the  cochlear.  The  turning  and  caloric  tests  enable  us  to  analyze 
the  function  of  the  vestibular  labyrinth  just  as  the  tuning-fork 
and  other  tests  of  hearing  enable  us  to  study  the  auditory.  It  is 
distinctly  unfortunate  that  at  the  present  time  among  otologists 
at  large  there  are  two  misconceptions  in  regard  to  this  study; 
unquestionably  many  aurists  hesitate  to  undertake  this  work  be- 
cause of  these  misconceptions.  In  the  first  place,  the  impression 
is  general  that  a  study  of  the  internal  ear  and  its  intracranial 
pathways  is  neurologic  work;  and  in  the  second  place,  there  is  no 
question  that  such  examinations  are  regarded  as  extremely  diffi- 
cult. No  one  disputes  that  an  examination  of  the  internal  ear 
itself  to  determine  its  own  integrity  is  a  task  for  the  otologist; 
Barany  has  made  it  evident,  how^ever,  that  in  testing  the  internal 
ear  we  are  at  the  same  time  testing  its  intracranial  pathways. 
While  it  is  true  that  information  obtained  as  to  the  condition  of 
the  intracranial  pathwaj^s  is  of  neurologic  value,  it  is  nevertheless 
elicited  by  ear-tests,  and  for  that  reason  is,  of  course,  an  otologic 
study.  There  is  an  exact  analogy*  in  the  relation  of  the  ophthal- 
mologist to  intracranial  cases ;  the  eye-examination  furnishes  infor- 
mation of  value  to  the  neurologist  and  yet  no  one  considers  that 
such  a  study  is  merely  neurologic.  The  otologist  in  precisely  the 
same  way  ''looks  into  the  brain"  by  way  of  the  ear. 

The  other  misconception  is  that  this  work  is  enormously  diffi- 

67 


68  EQUILIBRIUM  AND  VERTIGO 

cult.  As  a  matter  of  fact  those  who  are  familiar  with  this  work 
know  that  it  is  not  in  any  sense  more  diflficnlt  than  any  other  form 
of  ear-examination  thoroughly  done.  It  is  the  newness  of  the 
work  alone  that  is  responsible  for  this  misconception.  The  entire 
physiology  of  these  ear-tests,  instead  of  being  regarded  as  bewil- 
dering and  complex,  may  be  summed  up  in  four  sentences,  as 
follows : 

(1)  The  eyes  are  always  drawn  in  the  direction  of  the  endo- 
lymph  movement. 

(2)  The  vertigo  is  always  in  a  direction  opposite  to  the  endo- 
lympli  movement,  {a)  Past-pointing  is  always  in  a  direction  oppo- 
site to  the  vertigo;  {h)  falling  is  always  in  a  direction  opposite  to 
the  vertigo. 

Merely  by  knowing  these  laws  the  otologist  is  then  master  of 
the  physiology  of  this  subject.  All  the  combinations  and  permu- 
tations of  the  responses  to  ear-stimulation  follow  these  simple  laws, 
and  it  is  therefore  not  necessary  for  the  otologist  to  devote  years 
of  study  to  this  particular  subject  before  he  feels  himself  equipped 
to  undertake  the  tests. 

Just  so  long  as  the  otologist  looks  upon  this  study  as  neuro- 
logic and  as  extremely  complicated  and  abstruse,  he  will  be  de- 
priving himself  of  a  valuable  method  of  routine  examination  of  ear 
conditions,  and  also  of  large  opportunities  in  extending  his  field 
of  usefulness. 

From  the  standpoint  of  the  otologist,  the  most  useful  applica- 
tion of  this  study  is  in  the  routine  every-day  examination  of  ear 
cases.  Even  in  arriving  at  a  conclusion  as  to  the  condition  of  the 
cochlea,  these  tests  are  often  invaluable.  Every  otologist  is  con- 
stantly confronted  with  cases  of  deafness  in  which  the  significance 
of  the  tuning-fork  tests  is  obscure  and  inconclusive.  If  in  these 
cases  one  can  demonstrate  an  involvement  of  the  kinetic-static 
labyrinth,  which  is  so  readily  done  by  these  tests,  he  has  strong 
presumptive  evidence  of  a  similar  impairment  of  the  cochlear  por- 
tion of  the  internal  ear.  Stimulation  of  the  internal  ear  by  turn- 
ing and  douching  has  this  advantage  over  the  accepted  methods 
of  testing  the  internal  ear  in  that  we  have  in  the  resulting  nystag- 


THE  INTERNAL  EAR  AND  THE  OTOLOGIST  69 

mus,  past-pointing  and  falling,  the  clean-cut,  quantitative,  objective 
evidence  of  the  function  of  the  kinetic-static  portion  of  the  labyrinth 
and  VIII  Nerve.  The  tuning-fork  and  other  tests  of  the  cochlea, 
on  the  contrary,  are  subjective  and  depend  entirely  on  the  intelli- 
gence, honesty  and  co-operation  of  the  patient.  The  ability  of 
the  examiner  to  see  and  measure  responses  from  ear-stimulation, 
such  as  nystagmus  and  falling,  is  a  different  matter;  it  enables 
him  to  state  with  greater  assurance,  "Yes"  or  "No,"  as  to  the 
involvement  of  the  internal  ear.  In  cases  in  which  the  examination 
of  the  cochlea  shows  practically  normal  hearing  with  the  single 
exception  that  there  is  a  marked  diminution  of  bone-conduction, 
the  otologist  has  been  accustomed  immediately  to  suspect  some 
systemic  affection,  such  as  syphilis.  Here  the  new  ear-tests  are 
especially  useful ;  turning  or  douching  shows  definitely  whether 
the  internal  ear  is  or  is  not  affected. 

In  routine  examination  of  ear-cases  it  is,  of  course,  not  neces- 
sary to  conduct  all  the  tests.  An  examination  lasting  only  two 
or  three  minutes  is  usually  sufficient ;  merely  by  turning  the  patient 
ten  times  to  the  right  and  obtaining  26  seconds  of  after-turning 
nystagmus,  we  at  once  can  conclude  that  both  the  static  labyrinths 
are  normal.  It  is  best,  however,  to  turn  again  to  the  left  to  make 
sure  that  the  nystagmus  thus  obtained  is  also  normal.  Very  often, 
however,  the  nystagmus  will  prove  to  be  subnormal  and«  imme- 
diately we  have  a  hint  as  to  the  necessity  for  further  study.  We 
have  no  hesitancy  in  suggesting  that  if  the  otologist  in  routine 
work  will  make  such  a  single  test,  he  will  be  surprised  to  find  that 
in  many  instances  an  entirely  new  lignt  is  thrown  upon  the  condition 
of  his  patient.  These  tests  do  not  produce  any  discomfort  to  the 
patient,  provided  that  too  many  tests  are  not  attempted  at  one 
sitting.  A  few  words  explaining  the  object  of  the  tests  does  away 
with  any  feeling  oiapprehension  that  the  patient  might  have. 

When  the  otologist  is  confronted  with  surgical  problems  of 
the  internal  ear  itself,  as  in  inflammatory  conditions  of  the  laby- 
rinth resulting  from  an  extension  of  a  suppurative  process  in  the 
middle  ear,  it  is  generally  recognized  that  the  turning  and  caloric 
tests,  and  occasionally  the  fistula  test,  are  indispensable  in  deter- 


70  EQUILIBRIUM  AND  VERTIGO 

mining  the  nature  and  degree  of  involvement.  These  tests  are  the 
only  means  by  which  the  aural  surgeon  can  determine  whether 
operation  on  the  labyrinth  is  or  is  not  necessary. 

Vestibular  symptoms  produced  by  non-surgical  affections  re- 
sult from  lesions  either  of  the  labyrinth  itself  or  along  the  intra- 
cranial nerve-pathways  from  the  internal  ears.  Such  a  differen- 
tiation can  be  made  only  by  a  study  of  the  internal  ear,  so  that 
vertigo  from  whatever  cause  properly  belongs  in  the  domain  of 
otology.  When  examining  the  internal  ear  in  an  attempt  to  deter- 
mine its  integrity,  the  turning  and  caloric  tests  furnish  the  neces- 
sary information  in  that  they  either  do  or  do  not  produce  nystag- 
mus, vertigo,  past-pointing  and  falling;  but  in  order  to  produce 
these  phenomena  not  only  the  internal  ear  but  the  pathways  from 
the  internal  ear  to  the  various  nerve-centres  in  the  brain  must 
necessarily  be  intact.  In  conducting  the  ear-tests,  therefore,  we 
are  examining  not  only  the  internal  ear  itself,  but  the  vestibular 
apparatus  within  the  brain.  The  otologist  is  therefore  able  in 
this  way  to  furnish  information  as  to  the  location  of  intracranial 
lesions  that  involve  the  various  pathways  of  the  vestibular  appa- 
ratus. In  this  broader  field  of  intracranial  localization  the  otolo- 
gist has  only  made  a  beginning.  The  field  is  large  and  the  possi- 
bilities enormous ;  but  it  will  require  the  combined  work  of  many 
otologists  throughout  the  world  to  develop  such  a  study  to  the  full 
limit  of  its  possibilities. 

Summarizing,  these  neuro-otologic  studies  are  of  value  to  the 
otologist  in  the  following  ways,  stated  in  the  order  of  their  impor- 
tance: (1)  In  the  routine  study  of  ear-cases;  (2)  in  determining  the 
cause  of  vertigo  no  matter  what  its  origin  may  be,  and  (3)  in  intra- 
cranial localization. 


PART  II 

THE  STUDY  OF  THE  INTERNAL  EAR 


CHAPTER  X 

THE   DEVELOPMENT    OF   NEURO-OTOLOGY 

Although  it  is  only  in  the  past  few  years  that  the  ear  lias  come 
to  be  recognized  as  the  sense-organ  of  equilibration,  yet  in  a  gen- 
eral vague  way  certain  principles  in  regard  to  equilibration  have 
been  the  subject  of  speculation  by  scientists  through  many  cen- 
turies. Even  the  ancients  knew  that  the  prolonged  turning  of  an 
individual  produced  vertigo  and  disturbance  of  equilibration;  how- 
ever, they  did  not  of  course  recognize  that  it  was  in  any  sense  an 
ear-phenomenon.  In  fact,  it  was  not  until  the  past  century  that  a 
knowledge  of  this  relation  became  recognized.  It  is  of  interest 
to  note  that  the  very  first  work  on  the  relation  of  the  ear  to  equi- 
librium and  nystagmus  was  brought  forth  at  about  the  same  time 
by  two  men  who  were  working  entirely  independently.  In  1825 
Flourens  made  excisions  of  portions  of  the  labyrinths  of  animals 
and  noted  that  this  caused  movements  of  the  eyes  and  definite 
disturbances  of  equilibration  ;  Purkinje  at  the  same  time  conducted 
experiments  in  turning  human  beings  and  likewise  observed  the 
resulting  nystagmus  and  vertigo.  It  was  Meniere  who  clearly 
recognized  that  attacks  of  vertigo  have  a  definite  clinical  relation- 
ship to  diseased  ears.  This  subject  was  further  advanced  by  Goltz, 
who  in  1870  first  propounded  a  theory  of  the  physiology  of  the 
semicircular  canals.  Further  advances  were  made  by  the  investi- 
gations of  Breuer,  Mach,  Crum-Brown,  Bezold,  Ewald,  de  Cyon 
and  others.  The  work  of  these  men  was  utilized  by  von  Stein, 
of  Moscow,  and  Hog^^es,  a  Hungarian,  who  made  the  first  systema- 
tized contribution  to  the  study  of  the  internal  ear.  The  studies 
of  Hogyes  represent  a  life  work  of  earnest  effort  and  unbiased 
observation,  which  were  not  translated  from  the  Hungarian  until 
a  few  years  ago,  but  were  carefully  studied  in  the  original  by 
Robert  Barany  and  was  one  of  the  contributions  which  made 
possible  the  phenomenal  work  of  Barany.  The  efforts  of  the 
very  earliest  investigators  were  entirely  along  scientific  lines ;  the 

73 


74  EQUILIBRIUM  AND  \  ERTIGO 

practical  application  of  these  investigations  fell  to  the  lot  of  the 
Vienna  School  of  Otologists,  notably  Barany,  Neumann,  Ruttin, 
Alexander  and  Kreidl.  These  men  have  set  the  stamp  of  Vienna 
indelibly  upon  the  study  of  the  kinetic-static  labyrinth.  In  the  past 
ten  years  Robert  Barany  especially  has  done  his  monumental  work 
in  extending  the  field  of  this  study  into  the  realm  of  neurolog>'. 
For  this  contribution  he  received  the  prize  of  the  year  from  the 
Society  of  German  Neurologists,  1913,  which  is  of  particular  signifi- 
cance in  that  it  was  an  ear  specialist  who  received  a  neurologic 
prize.  The  awarding  of  the  Nobel  prize  to  Barany  two  years  later 
was  the  first  general  world-wide  recognition  of  the  great  clinical 
importance  of  these  studies  of  the  internal  ear. 

The  work  of  Barany  in  this  connection  is  so  unique  that  it  is 
of  interest  to  give  his  own  version  of  how  he  first  made  these 
discoveries.  In  1905  Barany  observed  that  douching  suppurating 
ears  with  water  that  was  either  too  cold  or  too  hot,  not  only  pro- 
duced vertigo  and  nystagmus  but  that  the  nystagmus  was  of  a 
definite  type  and  in  a  definite  direction.  He  noted  further  that 
the  direction  of  the  nystagmus  produced  by  water  that  was  too 
cold  was  in  a  diametrically  opposite  direction  to  the  nystagmus  pro- 
duced by  water  that  was  too  hot.  He  then  douched  the  ears  of 
normal  individuals  (with  intact  drum-heads)  and  produced  the 
same  results.  It  was  on  the  basis  of  these  observations  that 
Barany  gave  to  the  world  the  caloric  test. 

The  next  advance  in  this  field  was  the  contribution  of  Ramon  y 
Cajal  who,  in  1909,  demonstrated  histologically  that  the  vestibular 
fibres  from  the  internal  ear  continue  into  the  cerebellum.  Barany 
was  impressed  with  the  significance  of  this  discovery  and  realized 
the  possibilities  of  ear-study  in  relation  to  the  cerebellum.  It 
had  been  only  a  few  years  previous,  in  1906,  that  Bolk  had  advanced 
the  theory  of  cerebellar  localization,  based  upon  researches  in 
comparative  anatomy.  It  was  but  a  step  for  Barany  to  link  to- 
gether the  work  of  Cajal  and  Bolk  and  work  out  his  own  conception 
of  the  uses  of  ear-study  in  cerebellar  localization. 

In  the  United  States,  the  most  important  contributions  to  this 
study  have  been  made  by  Mills,  Shanibaugli,  E.  R.  Lewis,  George 


THE  DEVELOPMENT  OF  NEURO-OTOLOGY  75 

Mackenzie,  Friesner,  Braun,  J.  G.  Wilson  and  Pike.  Mills,  in 
his  textbook  on  Diseases  of  the  Nervous  System  discussed  at 
length  the  affections  of  equilibration  due  to  disease  of  the  vestibu- 
lar nerve  and  its  related  encephalic  structures ;  this  is  one  of  the 
first,  if  not  the  first  instance,  in  which  an  effort  was  made  to  group 
the  facts  relating  to  the  symptomatology  of  affections  of  the  ves- 
tibular nerve  and  its  correlated  tracts.  Shambaugh,  upon,  the 
basis  of  extensive  histologic  work,  has  made  many  original  con- 
tributions to  the  subject  of  the  minute  anatomy  of  the  internal  ear,, 
especially  in  showing  that  there  are  more  hair-cells  on  one  side 
of  each  crista  than  on  the  other  and  in  demonstrating  the  relation 
of  the  cupula  to  the  hair-cells  of  the  crista.  E.  R.  Lewis  has  made 
the  most  valuable  contributions  in  this  country  to  the  "mechanics"" 
of  vestibular  action  and  made  clear  the  co-working  of  the  two 
vertical  semicircular  canals.  George  Mackenzie  has  Avorked  out 
to  its  highest  efficiency  the  uses  of  the  galvanic  tests  of  the  internal 
ear,  and  also  has  made  original  observations  regarding  the  normal 
duration  of  after-turning  nystagmus ;  Friesner  and  Braun,  in  their 
books,  ''The  Labyrinth"  and  "Cerebellar  Abscess,"  have  written 
the  first  comprehensive  works  in  English  on  these  subjects ;  and 
Wilson  and  Pike,  by  their  experimental  work  on  animals,  have 
greatly  advanced  the  study  of  the  relation  of  the  ear  to  the  central 
nervous  system. 


CHAPTER  XI 

ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS  OF  THE 
LABYRINTH  AND  VIII  NERVE 

In  order  to  examine  the  internal  car  and  otlier  portions  of 
the  vestibular  apparatus  intelligently,  and  to  interpret  the  signifi- 
cance of  the  findings,  it  is  absolutely  necessary  to  understand  the 
essential  features  of  the  anatomy  and  physiology  of  the  parts 
involved.  It  is  our  definite  purpose  to  present  only  those  con- 
siderations of  the  anatomy  and  physiolog}^  which  deal  directly 
with  the  relation  of  the  ear  to  the  central  nervous  system.  The 
otologist  is  naturally  familiar  with  the  structure  and  the  functions 
of  the  internal  ear ;  this  chapter  is  therefore  written  more  especially 
for  the  general  practitioner,  ophthalmologist,  syphilologist,  neu- 
rologist and  surgeon,  in  order  that  they  may  be  reminded  of  the 
fundamental  principles  unrlerlying  the  tests  of  the  labyrinth. 
Having  once  visualized  the  mechanism  of  the  internal  ear,  one  is 
then  in  a  position  not  only  to  perform  the  tests  but  to  understand 
and  interpret  the  resulting  phenomena. 

Anatomic   Coksideeations 

The  labyrinth  is  a  series  of  intercommunicating  spaces  situated 
within  the  petrous  portion  of  the  temporal  bone,  and  contains  a 
membranous  sac  known  as  the  membranous  labyrinth.  The  bony 
labyrinth  consists  of  a  central  chamber  called  the  vestibule  from 
which  there  extend  anteriorly  a  coiled  tube  known  as  the  cochlea 
and  posteriorly  three  tubes  known  as  the  semicircular  canals 
(Fig.  3). 

The  cochlear  tube  is  arranged  in  a  spiral  of  two  and  a  half 
turns.  The  three  semicircular  canals  are  placed  at  right  angles 
to  each  other  in  three  different  planes  of  space,  and  are  known 
as  the  "horizontal"  or  external  canal,  the  superior  (vertical) 
canal  and  the  posterior  (vertical)  canal.  The  superior  canal  lies  in 
a  plane  halfway  between  the  frontal  and  the  sagittal;  the  outer- 

76 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS     77 


78 


EQITILIBRIUM  AND  VERTIGO 


most  portion  is  placed  anteriorly  and  the  plane  continues  in- 
ward and  backward.  The  posterior  canal  also  lies  in  a  plane 
halfway  between  the  frontal  and  the  sagittal;  the  outermost 
portion,  however,  is  placed  posteriorly  and  the  plane  continues 


Fio.  4. — Head  inclined  30°  forward.  Dotted  line  between  the  external  auditory  canal  and  the  external 
canthus  is  parallel  to  the  floor;  this  places  horizontal  canal  in  a  horizontal  plane  and  vertical  canals  in  a 
vertical  plane. 


forward  and  inward.  The  superior  canal  of  the  right  ear  and  the 
posterior  canal  of  the  left  ear  are  situated  in  parallel  planes; 
similarly  the  superior  canal  of  the  left  ear  and  the  posterior 
canal  of  the  right  ear  occupy  parallel  planes.  AVhen  the  head  is 
inclined  30  deqrees  forward  the  horizontal   canal  then  lies  in  a 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS    7<^ 

plane  exactly  parallel  with  the  floor,  and  the  vertical  canals,  the- 
siiperior  and  posterior,  are  at  exactly  right  angles  to  the  floor. 


Fig.  5. — Head  inclined  120°  forward.  Dotted  line  between  the  external  auditory  meatus  and  the- 
external  canthus  is  at  right  angles  to  the  floor;  this  places  horizontal  canal  in  a  vertical  plane  and  the- 
vertical  canals  in  a  horizontal  plane. 


This  position  of  the  head  is  important  to  bear  in  mind,  as  it  must 
he  nsed  routinely  in  testing  the  semicircular  canals  (Fig.  4,  Fig.  5,. 
and  Fig.  6). 


80  EQUILIBRIUM  AND  VERTIGO 

Each   semicircular  canal  has   at  one  end  a  bulbous  swelling 
known  as  the  ampulla.    The  other  end  of  the  horizontal  canal  leads 


^: 


:-^-«M»l|»M.,:>i.„,„. 


Pic  0 — Head  inclined  60°  backward.  Dotted  line  between  the  external  auditory  meatus  and  the 
externalcanthus  is  at  right  angles  to  the  floor;  this  places  the  horizontal  canal  in  a  vertical  plane  and  the 
vertical  canals  in  a  horizontal  plane. 

directly  into  the  vestibule,  whereas  the  smooth  non-ampullated 
ends  of  the  superior  and  posterior  canals  unite  in  a  common  tube 
which  in  turn  opens  into  the  vestibule. 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS     81 

The  membranous  labyrinth  is  the  true  labyrinth  and  is  embryo- 
logically  the  primary  formation;  the  bony  capsule  is  a  later  de- 
velopment and  conforms  itself  to  the  general  shape  of  the  original 
membranous  labyrinth.  Primarily  in  the  lower  forms  of  life  as 
as  well  as  in  the  embryo,  the  internal  ear  consists  of  a  small  sac, 
which  eventually  in  the  higher  forms  of  life  differentiates  into  an 
anterior  cochlear  portion  and  a  posterior  vestibular  portion.  In 
each  animal  this  ear-sac  develops  that  portion  which  is  most  essen- 
tial to  its  environment — ^the  fish  develops  semicircular  canals  but 
has  no  cochlea ;  the  bird  has  a  very  highly  developed  semicircular 
canal  sj^stem  and  also  has  a  cochlea.  It  is  in  mammals  and  man 
that  the  cochlea,  in  addition  to  the  other  portions  of  the  internal 
ear,  attains  its  highest  development. 

The  membranous  labyrinth  occupies  approximately  one-third 
of  the  lumen  of  the  bony  labyrinth  and  is  attached  to  the  bony 
walls  by  fibrous  bands  at  the  point  of  exit  of  the  nerve-fibres.  It 
is  a  counterpart  of  the  bony  labyrinth  in  all  its  parts  except  that 
portion  lying  within  the  vestibule;  this  portion  (corresponding  to 
the  vestibule)  is  subdivided  into  two  sacs  known  as  the  saccule  and 
the  utricle.  The  meml^nous  labyrinth  is  a  closed  sac  and  con- 
tains a  flmd  of  high  specific  gravity,  the  endolymph,  which  has  no 
means  of  escape.  This  entire  structure  floats  in  a  fluid  of  lower 
specific  gravity  known  as  the  perilymph,  which  fills  the  bony 
labyrinth;  in  contrast  with  the  endolymph,  this  perilymph  does 
have  a  means  of  escape,  having  a  direct  communication  with  the 
rest  of  the  cerebro-spinal  fluid  through  a  small  tube,  which  opens 
into  a  subarachnoid  space. 

The  actual  sense-organs  of  the  internal  ear  are  contained  within 
the  membranous  labyrinth.  The  labyrinthine  end-organ  is  essen- 
tially a  hair-cell  adapted  to  receive  stimuli  from  wave-impulses  of 
the  endolymph  impinging  upon  the  hairs.  Within  the  cochlea 
these  hair-cells  are  grouped  into  an  auditory  apparatus  known  as 
the  Organ  of  Gorti;  3000  to  6000  units  of  Corti's  organ  extend 
throughout  the  entire  cochlear  tube.  The  second  type  of  end- 
organ,  known  as  i\\e  macula,  is  found  in  the  saccule  and  the  utricle, 
one  in  each.     The  third  type  of  the  end-organ  is  found  in  tha 

6 


82  EQUILIBRIUM  AND  VERTIGO 

ampulla  of  each  semicircular  canal;  the  hair-cells  are  grouped  in 
a  ridge  or  crest  known  as  the  crista.  The  sense-organs  then  of  the 
kinetic-static  labyrinth,  instead  of  consisting  of  a  continuous  organ 
as  in  the  cochlea,  are  definitely  five  in  number — the  macula  of  the 
saccule,  the  macula  of  the  utricle,  and  the  three  cristas  of  the  three 
semicircular  canals.  The  macula  of  the  saccule  is  an  oval  spot 
extending  across  the  floor  of  the  saccule  in  the  frontal  plane  of 
the  head.  The  macula  of  the  utricle  extends  in  the  antero-pos- 
terior  or  sagittal  plane  of  the  head.  The  two  maculae,  therefore, 
are  at  right  angles  to  each  other. 

Overlying  each  of  these  end-organs  is  a  gelatinous  substance; 
in  the  cochlea  it  is  found  overlying  the  units  of  the  Organ  of  Corti 
and  is  known  as  the  tectorial  membrane.  Over  the  macula  of  the 
saccule  and  also  over  the  macula  of  the  utricle  there  extends  a 
so-called  otolith  membrane,  which  contains  tiny  calcareous  nodules 
known  as  otoliths.  The  hairs  of  the  crista  of  each  semicircular 
canal  are  likewise  surrounded  by  a  gelatinous  substance  known 
as  the  cupula. 

Briefly  then,  the  end-organ  of  the  cochlea  is  the  Organ  of  Corti; 
that  of  the  saccule,  as  also  of  the  utricle,  is  the  macula ;  whereas 
that  of  each  semicircular  canal  is  the  crista.  The  hair-cells  of  these 
various  sense-organs  are  the  origin  of  all  the  peripheral  filaments 
of  the  VIII  Xerve.  The  filaments  from  the  saccule  and  the  fila- 
ments from  the  posterior  semicircular  canals  unite  to  form  one 
bundle  which  enters  Scarpa's  ganglion  in  the  internal  auditory 
canal.  The  filaments  from  the  utricle  unite  with  those  from  the 
superior  and  horizontal  canals  to  form  another  bundle  which  also 
continues  to  Scarpa's  ganglion.  Scarpa's  ganglion  therefore  con- 
tains all  the  fibres  from  the  kinetic-static  labyrinth.  The  VIII 
Nerve  itself  consists  of  two  distinct  bundles,  a  cochlear  portion  and 
a  vestibular  portion,  united,  however,  Avithin  one  neurilemma.  The 
Nerve  is  approximately  one-half  inch  long  and  extends  from  the 
internal  auditory  canal  to  its  entrance  into  the  brain-stem  at  the 
junction  of  the  medulla  oblongata  and  pons,  where  it  again  breaks 
up  into  its  respective  cochlear  and  vestibular  portions. 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS    83 

Physiologic  Considerations 

Physiologically  the  internal  ear  may  be  divided  into  three  por- 
tions— the  acoustic  labyrinth  ooncerned  exclusively  with  the  func- 
tion of  hearing,  the  static  labyrinth,  for  the  maintenance  of  station, 
and  the  kinetic  labyrinth,  for  the  recognition  and  analysis  of 
motion.  The  entire  portion  of  the  internal  ear  concerned  in  main- 
taining equilibrium  has  heretofore  been  called  the  static  labyrinth ; 
this  organ,  however,  has  a  much  broader  use  than  merely  a  static 
function.  As  Randall  points  out,  there  is  this  third  function, 
which  he  has  termed  ''kinetic."  The  acoustic  function  is  limited 
to  the  cochlea,  the  static  function  is  limited  to  the  saccule  and 
utricle,  whereas  the  kinetic  function  is  presided  over  by  the  three 
semicircular  canals  and  also  probably  by  the  saccule  and  utricle. 
When  the  body  is  at  rest  the  otoliths  by  their  pressure  on  the 
maculae  of  the  saccule  and  utricle  give  information  as  to  the  position 
of  the  body;  this,  accurately  speaking,  is  the  static  function. 
The  kinetic  function  is  dependent  upon  the  entire  equilibratory 
portion  of  the  ear ;  the  three  semicircular  canals  take  cognizance  of 
rotary  movements  of  the  body  in  all  conceivable  planes.  Move- 
ments in  a  linear  direction,  anteroposteriorly,  are  probably  detected 
by  the  macula  of  the  utricle ;  linear  movements  in  a  lateral  direction 
are  appreciated  by  the  macula  of  the  saccule;  and  linear  move- 
ments in  a  vertical  direction,  up  and  down,  are  detected  by  both 
the  utricle  and  saccule. 

The  underlying  principle  of  the  physiology  of  the  labyrinth  is 
that  primarily  the  end-organ  is  a  hair-cell  stimulated  by  wave- 
impulses.  These  impulses  are  then  conducted  by  means  of  a  nerve- 
filament  from  the  hair-cell.  The  hairs  are  set  in  motion  by  waves 
of  the  endolymph.  In  the  organ  of  Corti  the  hair-cells  are  set  in 
motion  by  sound-waves  conducted  to  the  cochlea,  either  by  air  or 
bone.  Wave-impulses  in  the  external  ear  cause  a  movement  of  the 
drum-head;  these  impulses  are  carried  mainly  by  the  chain  of 
ossicles  through  the  foot-plate  of  the  stapes,  which  vibrates  in  the 
oval  window,  causing  similar  wave-like  movements  in  the  endo- 
lymph. These  in  turn  impinge  upon  the  hairs  of  the  organ  of 
Corti.     Sound-waves  may  also  be  transmitted  to  the  endolymph 


84  EQUILIBRIUM  AND  VERTIGO 

more  directly  by  bone-conduction ;  but  the  essential  feature  is  that 
the  stimuli  to  the  organ  of  Corti,  producing  the  appreciation  of 
sound,  originate  in  the  external  world.  ( )n  the  other  hand,  in  sharp 
contrast,  the  hair-cells  of  the  kinetic  labyrinth  are  usuall}^  set  in 
motion  by  the  movement  of  the  body  itself  and  not  by  an  external 
wave-impulse.  If  the  body  moves  forward  in  a  linear  direction 
there  results  a  lagging  behind  of  the  otoliths  above  the  macula 
of  the  utricle.  If  the  body  moves  sideways  there  is  a  lagging 
behind  of  the  otoliths  above  the  macula  of  the  saccule.  A  rotary 
movement  of  the  body  causes  movement  of  the  endolymph  in  one 
or  more  of  the  semicircular  canals,  thereby  affecting  certain  of 
the  hairs  in  the  corresponding  crista  or  cristae.  When  the  current 
of  the  endolymph  is  toward  the  ampulla,  the  hairs  of  that  side 
are  put  upon  the  stretch;  if  the  current  is  away  from  the  ampulla 
the  hairs  of  the  opposite  side  of  the  crista  are  put  upon  the  stretch. 
The  hair-cells  of  the  two  sides  of  the  crista  are  connected  by 
separate  nerve-fibres  with  different  central  nuclei  and  because 
of  this  arrangement  it  is  possible  for  the  cells  of  one  side  of  the 
crista  to  produce  diametrically  opposite  phenomena  from  the 
stimulation  of  the  cells  of  the  other  side  of  the  same  crista. 

Figure  7  shows  the  lumen  of  the  horizontal  membranous  canal; 
the  bulging  portion  of  the  outer  end  is  the  ampulla  and  from  the 
external  portion  projects  the  crista.  It  has  been  proven  experi- 
mentally that  a  current  toward  the  ampulla  in  the  horizontal  canal 
produces  twice  as  strong  a  reaction  as  a  current  away  from  the 
ampulla.  This  is  represented  diagrammatically  by  two  hairs  on 
one  side  of  the  crista  and  one  hair  on  the  other  side.  Figure  8 
represents  the  current  away  from  the  ampulla ;  it  will  be  noted  that 
the  one  hair  is  therefore  put  upon  the  stretch,  whereas  the  two 
hairs  on  the  opposite  side  are  relaxed.  In  Figure  9,  on  the  other 
hand,  with  the  current  toward  the  ampulla,  the  two  hairs  are 
put  upon  the  stretch,  whereas  the  one  hair  on  the  opposite  side  is 
relaxed.  Figure  10  represents  the  vertical  canals,  the  superior 
and  the  posterior,  uniting  in  one  common  crus.  In  the  vertical 
canals  the  sense-organs  are  so  constructed  that  the  current  away 
from  the  ampulla  is  twice  as  powerful  as  the  current  toward  the 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS    85 


Fig.  7. — Scheme  of  the  right  horizontal  canal. 


Fig.  8.— Current  away  from  the  ampulla  in  the  right  horizontal  canal.     (Only  one-third  of  the 
hairs  are  put  upon  the  stretch.) 


86 


EQUILIBRIUM  AND  VERTIGO 


Fro.  9. — Current  toward  the  ampulla  in  the  right  horizontal  canal.      (Two-thirds    of   the 
hairs   are  put  upon  the  stretch.) 


Posterior 


Super/or 


Fig.  10. — The  vertical  semicircular  canals  (right). 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS    87 


Posierior 


Superior 


Fig.  H. — Current  away  from  the  ampullae. 


Posterior 


Superior 


Fig.  12. — Current  toward  the  ampullse. 


88  EQUILIBRIUM  AND  VERTIGO 

ampulla — just  the  opposite  from  the  mechanism  of  the  horizontal 
canal.  Figure  11  shows  that  the  current  away  from  the  ampullae 
puts  the  two  hairs  of  each  crista  upon  the  stretch,  whereas  the 
one  hair  is  relaxed.  Figure  12  shows  that  the  current  tow^ards  the 
ampullae  ijuts  only  one  hair  of  each  crista  upon  the  stretch,  whereas 
the  other  two  in  each  ampulla  are  relaxed.  It  will  be  noted  that 
the  current  either  away  from  or  toward  the  ampullae  of  the  vertical 
canals  has  an  identical  effect  upon  both  the  superior  and  the  pos- 
terior canal  mechanism. 

It  is  true  that  the  actual  calibre  of  the  membranous  labyrinth  is 
so  minute  that  it  is  inconceivable  to  consider  a  free  circulation 
of  the  fluid  within  it.  It  may  be  as  Neumann  suggests,  the  actual 
movement  occurs  in  the  perilymph  inducing  molecular  movement 
in  the  endolymph.  It  is  not  necessary,  however,  that  there  should 
be  a  free  movement  Avithin  the  endolymph,  as  even  the  slightest 
impulse  can  appreciably  affect  the  sensitive  hairs  projecting  into 
the  lumen  of  the  semicircular  canals.  We  do  know,  clinically, 
that  the  only  explanation  of  the  actual  phenomena  \ve  observe  is 
that  there  is  a  movement  of  the  endolymph.  Barany  has  shown 
that  douching  the  ear  with  the  head  forward  produces  exactly  the 
opposite  responses  from  douching  the  ear  with  the  head  backward. 
The  necessity  of  considering  that  there  is  an  endolymph  move- 
ment may  be  proved  as  follows:  Incline  the  head  backward  60°; 
this  puts  the  horizontal  canal  in  the  vertical  position.  Douching 
the  right  ear  with  cold  Avater  then  produces  (1)  horizontal  nvstag- 
mus  to  the  left,  (2)  sensation  of  roUins:  to  the  left,  (3)  past-pointing 
to  the  right,  and  (4)  a  rolling  or  falling  to  the  right. 

Now  without  any  further  douching,  merely  tilt  the  head  for- 
ward 120°,  which  puts  the  horizontal  canal  in  the  vertical  plane, 
but  exactly  upside  down  from  its  previous  position ;  there  imme- 
diately appear  (1)  horizontal  nvstagnms  to  the  right,  (2)  sensation 
of  rolling  to  the  right,  (3)  past-pointing  to  the  left,  and  (4)  a  roll- 
ing or  falling  to  the  left. 

This,  of  course,  disposes  absolutely  of  the  theory  that  cold 
water  causes  a  depression  and  hot  water  causes  a  stimulation  of 
the  hair-cells  of  the  crista.     Merely  by  altering  the  position  of 


ANATOMIC  AND  PHYSIOLOGIC  CONSIDERATIONS    89 

the  head  there  are  produced  diametrically  opposite  phenomena,  and 
a  movement  of  the  endolymph  is  the  only  explanation  for  this 
clinical  fact. 

Whereas  anatomically  each  semicircular  canal  is  actually  little 
more  than  a  half-circle,  physiologically  it  may  best  be  regarded 
as  a  circular  canal;  so  far  as  the  movement  of  the  endolymph  is 
concerned  a  complete  circle  is  made  through  the  utricle  which 
unites  the  two  ends  of  the  anatomically  sewi-eircular  canal. 

In  considering  the  physiology  of  the  internal  ear,  one  is  neces- 
sarily impressed  with  the  curious  fact  that  two  organs  of  such 
diversely  different  functions — the  organ'  of  hearing  and  the  organ 
of  balance — should  be  housed  in  one  common  cavity.  The  anatomy 
of  these  two  organs  of  utterly  different  functions  is  almost  identi- 
cal. There  is  not  only  a  continuous  bony  capsule  within  which 
this  double  organ  is  contained,  but  the  actual  membranous  internal 
ear  itself  is  one  continuous  sac,  containing  the  endoljmiph  which 
has  a  direct  communication  from  the  farthermost  point  of  the 
cochlea  anteriorly  to  the  farthermost  point  of  the  semicircular 
canals  posteriorly.  The  endolymph  itself  is  the  same  in  the  cochlea, 
the  saccule  and  utricle  and  the  canals.  The  actual  nerve-mechan- 
ism is  very  similar — practically  identical ;  the  auditory  unit  of 
the  cochlea  is  analogous  to  that  of  the  macula  of  the  vestibular 
sacs  and  of  the  crista  of  each  semicircular  canal.  Furthermore, 
on  all  of  these  structures  are  cells  with  projecting  hairs.  Again, 
at  the  end  of  these  hairs,  in  each  instance  there  is  a  mem- 
brane-like substance — the  tectorial  membrane  over  the  organ 
of  Corti,  the  otolith-membrane  over  each  macula,  and  the  cupula 
over  each  crista. 

In  spite  of  the  almost  identical  anatomical  construction  of 
these  various  sense-organs,  they  have  widely  different  functions. 
Why  this  should  be  may  be  explained  by  considering  the  develop- 
ment of  the  internal  ear  as  seen  in  various  lower  forms  of  life. 
The  equilibratory  organ  was  one  of  the  earliest  special  senses  and 
made  its  appearance  almost  coincidently  with  life  itself.  This 
primitive  sense-organ  depended  entirely  for  its  impulses  upon 
shocks  and  concussions  occurring  in  its  environment.     The  sense 


90  EQUILIBRIUM  AND  VERTIGO 

of  hearing,  also  dependent  upon  external  wave-impulses,  was  an 
outgrowth  of  this  function.  As  W.  A.  Wells  suggests,  there  was 
already  developed  an  organ  for  the  reception  of  wave-impulses  and 
nature  had  but  to  add  an  annex  with  a  specialized  nerve-mechan- 
ism adapted  to  the  perception  of  vibrations  of  a  certain  periodicity, 
which  becoming  fused  are  appreciated  as  sounds, 

A  possible  connecting  link  between  the  sense  of  equilibration 
and  hearing,  as  seen  in  the  human  internal  ear,  is  suggested  by 
Bonnier  in  the  following  functions:  (1)  Baresthesia.  By  this  is 
meant  the  appreciation  by  the  saccule  and  the  utricle  of  the  pres- 
sure exerted  by  external  media  whether  liquid  or  air.  (2)  Seises- 
thesia.  By  this  is  meant  the  appreciation  by  the  utricle  and  sac- 
cule of  abrupt  variations  of  the  pressure  from  external  media. 
These  two  functions  are  neither  hearing,  on  the  one  hand,  nor 
the  sense  of  motion  or  station  on  the  other.  The  ability  of  the 
saccule  and  the  utricle  to  recognize  pressure  from  external  media 
might  well  be  regarded  as  an  intermediary  function  between  the 
sense  of  balance  and  the  sense  of  hearing. 

All  of  the  impulses  from  the  various  end-organs  within  the 
internal  ear  are  conducted  by  the  respective  nerve-filaments,  which, 
after  leaving  the  labyrinth,  form  the  VIIT  Nerve  and  continue  to 
their  respective  cells  or  centres.  After  reaching  the  brain-stem 
at  the  junction  of  the  medulla  oblongata  and  pons,  these  impulses, 
until  then  confined  within  the  VTTT  Nerve,  travel  along  widely 
divergent  paths. 


CHAPTER  XII 

MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM 

The  stereoscopic  photographs  shown  as  ilhistrations  for  this 
chapter  were  made  from  dissections  of  the  various  structures  con- 
cerned in  this  study— the  VIII  Nerve,  medulla  oblongata,  pons, 
the  three  joairs  of  cerebellar  peduncles,  the  cerebellum,  the  cerebral 
crura  and  the  posterior  portion  of  the  first  and  second  convolu- 
tions of  the  temporal  lobe.  It  is  within  these  structures  that  are 
contained  all  the  nerve-pathways  from  the  ear. 

The  vestibular  fibres  of  the  VIII  Nerve  pass  through  the 
medulla  oblongata  and  pons  on  the  way  to  the  cerebellum.  For 
clinical  purposes  it  is  convenient  to  speak  of  the  medulla  oblon- 
gata and  the  pons  as  one  structure — the  brain-stem  (Figs.  13,  14 
and  15).  The  brain-stem  commences  at  the  upper  termination 
of  the  spinal  cord  and  ends  at  the  upper  portion  of  the  pons  where 
it  divides  and  continues  as  the  two  cerebral  crura.  The  lower  por- 
tion of  the  brain-stem  is  the  medulla  oblongata  (Fig.  15).  It  is  one 
to  one  and  one-fourth  inches  long  and  resembles  a  somewhat  flat- 
tened cone.  Its  apex  or  lower  end  is  continuous  with  the  spinal  cord, 
while  the  upper,  broader  extremity  is  attached  to  the  pons.  An- 
teriorly, it  rests  upon  the  upper  surface  of  the  baso-occipital  bone 
and  shows  several  prominences.  The  two  swellings  inmaediately 
alongside  the  median  anterior  fissure  are  the  anterior  pyramids. 
Outside  of  these  are  two  other  swellings  corresponding  to  the  two 
olivary  bodies.  The  upper  portion  of  the  posterior  surface  forms 
a  triangular  area  and  is  the  floor  of  the  lower  part  of  the  IV 
ventricle  (Fig.  14). 

The  substance  of  the  medulla  oblongata  is  made  up  of  longi- 
tudinal and  curving  nerve  fibres  (most  of  them  the  continuation 
of  nerve  tracts  from  the  spinal  cord),  interspersed  Avith  masses  of 
gray  matter  or  nuclei.  It  is  of  interest  to  note  that  nuclei  of 
the  cranial  nerves  from  the  VIII  to  the  XII  inclusive  are  found 
within  the  medulla  oblongata.     In  its  upper  portion  there  are  also 

91 


92 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM    93 


94 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM       95 

found  three  collections  of  nerve-cells  constituting  the  Deiters' 
nucleus,  the  triangular  nucleus  and  Von  Becliterew's  nucleus. 
These  nuclei  receive  some  of  the  vestibular  fibres  from  the  VIII 
Nerve  after  it  enters  the  brain-stem. 

The  pons  or  the  upper  portion  of  the  brain-stem  (Fig.  15)  lies 
in  the  posterior  cranial  fossa  between  the  medulla  oblongata  below 
and  the  crura  cerebri  above.  It  is  a  cuboidal  mass  of  tissue  meas- 
uring about  an  inch  from  before  backward,  a  little  over  an  inch 
in  length  and  about  an  inch  and  a  half  from  side  to  side.  The 
anterior  surface  of  the  pons  consists  entirely  of  transverse  fibres 
arranged  in  three  groups — upper,  middle  and  lower.  These  pass 
to  the  lateral  surfaces  which  in  turn  continue  backwards  and  out- 
wards to  become  the  middle  peduncles  of  the  cerebellum. 

The  median  portion  of  the  posterior  surface  of  the  pons  (Figs. 
14,  16,  17)  forms  the  upi)er  part  of  the  floor  of  the  IV  ventricle. 
Among  other  anatomical  markings  can  be  seen  the  acoustic  tuber- 
cle which  extends  downward  to  the  medulla  oblongata,  while  cross- 
ing it  are  the  uppermost  of  the  acoustic  stria",  which  run  from 
behind  the  juxtarestiform  body  across  the  floor  of  the  IV  ventricle 
and  disappear  in  the  median  sulcus.  The  posterior  surface  of  the 
pons,  where  it  forms  the  floor  of  the  IV  ventricle,  consists  of  gray 
matter  in  which  are  found  the  dorsal  nuclei  of  the  VIII  Nerve, 
the  nuclei  of  the  VI  Nerve  and  the  sensory  and  motor  nuclei  of 
the  V  Nerve. 

The  inner  structure  of  the  pons  is  made  up  largely  of  masses 
of  fibres  both  longitudinal  and  transverse,  among  which  are  inter- 
spersed numerous  small  collections  of  gray  matter  known  as  the 
nuclei  pontis.  The  longitudinal  fibres  are  mainly  continuations 
of  the  pyramidal  tracts  running  from  the  cerebrum  to  the  spinal 
cord.  Of  the  transverse  fibres  there  is  one  commissural  tract 
uniting  the  two  lobes  of  the  cerebellum,  while  the  other  two  are 
decussating  tracts.  One  of  these  runs  from  the  cerebellum,  decus- 
sates and  terminates  in  the  opposite  side  of  the  pons;  the  other 
transverse  tracts  also  decussate  but  do  not  originate  in  the  cere- 
bellum. They  start  from  the  nuclei  pontis.  From  the  opposite 
side  of  the  pons  where  these  two  sets  of  transverse  tracts  terminate, 


96 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM    97 


98  EQUILIBRIUM  AND  VP:RTIG0 

the  fibres  continue  upward  to  the  cerebrum.  In  this  way  the  cere- 
bellum is  connortod  by  nerve-tracts  with  nuclei  in  both  sides  of  the 
pons. 

All  the  cranial  nuclei  concerned  in  nystagmus  are  located  in 
the  brain-stem  and  for  that  reason  are  of  particuhir  interest  in 
this  study.  The  nuclei  of  the  III  and  IV  cranial  nerves  are  located 
in  the  crura  cerebri  low  enough  to  be  in  relation  with  the  upper 
portion  of  the  pons.  In  the  lower  portion  of  the  ])ons  is  found 
the  only  other  nucleus  concerned  in  eye-movement,  the  VI,  or 
abducens.  AVhen  speaking  of  the  location  of  the  cranial  nerves 
in  relation  to  the  lirain-stem,  it  is  well  to  bear  in  mind  that  the 
cranial  nerves  have  both  a  deep  origin  and  a  superficial  exit.  The 
exit  of  the  cranial  nerves  from  the  III  to  the  XII  are  all  to  be 
found  on  the  lateral  and  ventral  aspects  of  the  pons  and  medulla 
oblongata.  The  origin  of  these  nerves  is  to  be  found  on  the  pos- 
terior aspect  of  the  pons  and  medulla  oblongata  and  in  close  rela- 
tion with  the  floors  of  the  III  and  the  IV  ventricles. 

In  order  that  lesions  may  involve  the  "cell  mass"  of  the  cranial 
nerves,  they  must  be  situated  in  the  extreme  dorsal  portions  of 
the  i3ons  and  medulla  oblongata;  root  fibres,  however,  may  be 
attacked  by  lesions  situated  anywhere  in  the  brain-stem.  It  might 
be  remarked,  in  passing,  that  the  VI  cranial  pair  of  nerves,  the 
abducens,  are  very  slender  structures  and  traverse  a  rather  lengthy 
course  outside  of  the  brain-stem.  For  that  reason  affections  any- 
where within  the  cranium  are  very  likely  to  affect  them  by  pres- 
sure, with  resulting  paralysis  or  paresis.  The  VII  and  VIII  cranial 
nerves  are  very  close  to  each  other,  almost  in  one  common  sheath. 
It  is  also  well  to  note  that  the  VIII  Nerve  is  very  much  softer  than 
its  neighbor,  the  A'll  Nerve,  so  that  when  both  are  involved  in  one 
lesion  it  is  not  at  all  uncommon  to  find  a  complete  loss  of  function 
of  the  VIII  Nerve,  whereas  the  VII  or  facial  nerve  is  only  slightly 
affected  because  of  its  greater  toughness  and  power  of  resistance. 

The  nerves  of  the  greatest  interest  in  our  study  are  the  III 
cranial  nerves  or  motor  oculi,  as  well  as  the  IV  and  VI  ]iairs  of 
cranial  nerves,  since  these  are  concerned  in  nystagmus.  The  X 
nuclei   are   of   interest   because    of   the    associating   nausea    and 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM      <)f) 

vomiting  which  often  result  from  stimuh^tion  of  the  other  cranial 
nerves  through  reflex  sources.    To  make  it  possible  for  the  III,  IV 
and  VI  cranial  nerves  to  work  in  harmou}^  there  must  necessarily 
be  a  connecting  link  of  fibres.     This  is  furnished  by  tlie  posterior 
longitudinal  bundles  which  are  located   in   the  posterior  portion 
of  the  crura,  pons  and  medulla  oblongata.    These  bundles  of  fibres 
not  only  connect  the  ocular  crania]  nuclei  with  each  other,  but  con- 
stitute the  anatomic  structure  which  makes  it  possible  for  all  of 
the  cranial  nerves  to  work  in  co-ordination.     For  example,  when 
a  person  looks  to  the  right  he  not  only  uses  the  right  external  rectus 
muscle,  but  also  the  left  internal  rectus,  and  there  must  also  be 
a  normal  antagonistic  action  of  the  other  ocular  muscles.    In  other 
words,  there  must  be  a  normal  co-ordination  of  the  right  VI  and 
left  III  nuclei,  and  to  a  lesser  extent  of  the  other  nuclei  controlling 
the  ocular  nmscles.    At  the  lower  portion  of  the  medulla  oblongata, 
the  posterior  longitudinal  bundles   become   continuous   with   the 
fibres  of  the  lateral  limiting  zone  and  with  the  fibres  of  the  antero- 
lateral ground  bundle,  which  probably  play  the  same  part  in  the 
cord  that  the  posterior  longitudinal  bundles  play  in  the  brain.    The 
))osterior  longitudinal  bundles  are  seen  in  the  pnns  and  medulla 
oblongata  as   two  triangular  bundles,   one  on  either  side   of  the 
central  raphe;  they  are  placed  immediately  below  the  gray  matter 
of  the  floor  of  the  IV  ventricle.     Motor  fibres   in  the  posterior 
longitudinal  bundles,  which  start  from  the  nucleus  of  the  III  Nerve, 
descend  to  the  pons,  where  they  join  the  VI  Nerve  of  the  same  side. 
Fibres  which  arise  in  the  nucleus  of  the  VI  Nerve  of  one  side  ascend, 
cross  the  middle  line,  and  join  thQ  fibres  of  the  III  Nerve  of  the 
opposite  side,  along  which  they  pasf^to  the  opposite  internal  rectus 
nuiscle,  thus  making  possible  co-ordinated  movements. 

The  IV  ventricle  is  a  rhomboidal,  lozenge-  or  diamond-shaped 
space.  It  is  situated  between  the  brain-stem  anteriorly  and  the 
cerebellum  posteriorly  (Figs.  14,  1(3,  17).  Its  lower  part  lies  in 
the  interior  of  the  medulla  oblongata,  while  the  upi)er  i)ortion  is 
situated  between  the  pons  in  front  and  the  cerebellum  behind.  Its 
anterior  boundary  is  the  so-called  floor  of  the  IV  ventricle.  The 
lower  extremity  of  the  ventricle  is  continuous  with   the  central 


100  EQUILIBRIUM  AND  VERTIGO 

canal  of  the  spinal  cord,  and  the  upper  end  is  continuous  with 
the  Aqueduct  of  Sylvius.  Tlie  lateral  boundaries  from  above  down- 
ward on  each  side  are  formed  by  the  superior  peduncle  of  the 
cerebellum,  the  middle  peduncle,  the  restiform  body  (or  inferior 
peduncle),  and  the  fasciculus  gracilis;  the  upper  part  of  the 
anterior  boundary  of  the  floor  is  formed  by  the  pons,  while  the  lower 
part  of  the  floor  is  formed  by  the  medulla  oblongata.  A  median 
sulcus  divides  the  floor  into  two  longitudinal  halves.  On  each 
side  of  this  shallow  sulcus  is  a  longitudinal  ridge  known  as  the 
fasciculus  teres.  In  the  lower  part  of  the  floor  these  two  fasciculi 
become  smaller  and  form  together  a  pointed  process  known  as 
the  calamus  scriptorius.  All  of  the  auditory  fibres  cross  at  this 
calamus  scriptorius  so  that  a  lesion  there  could  destroy  audition 
on  both  sides.  The  roof  of  the  IV  ventricle  is  formed  in  its  upper 
portion  by  the  two  superior  cerebellar  peduncles,  in  its  middle 
portion  by  the  vermis  of  the  cerebellum  into  which  it  extends  like 
a  slit,  and  in  the  lower  portion  by  the  posterior  wall  of  the  medulla 
oblongata. 

The  cerebellum  (Figs.  13,  18,  19,  20,  21)  lies  in  the  posterior 
fossa  of  the  cranium  behind  the  pons,  immediately  below  a  fold 
of  membrane  called  the  tentorium  cerebelli,  which  separates  it  from 
the  cerebrum  above.  Its  structure  is  made  up  of  an  outer  layer 
of  gray  matter  surrounding  a  core  of  white  matter  in  which  are 
imbedded  several  gray  nuclei,  among  them  the  three  vestibular 
nuclei,  globosis,  emboliformis  and  fastigii,  the  so-called  roof  nuclei, 
which  receive  the  vestibular  fibres  from  the  labyrinth.  The  cere- 
bellum (Figs.  22  and  23)  is  made  up  of  two  lateral  lobes  usually 
called  hemispheres,  connected  by  a  median  portion  known  as  the 
vermis.  The  vermis  of  the  cerebellum  is  the  most  primitive  portion 
and  is  the  only  lobe  present  in  fishes,  reptiles  and  birds.  The 
cerebellum  is  connected  with  the  brain-stem  by  three  pairs  of 
peduncles  (Figs.  22,  24),  the  two  superior  cerebellar-  peduncles 
above,  the  two  inferior  cerebellar  peduncles  below,  and  the  two 
middle  cerebellar  peduncles  between  the  other  two  pairs.  Eacli 
cerebellar  hemisphere  is  divided  into  a  superior  and  an  inferior 
portion ;  it  is  also  anatomically  divided  into  lobules,  but  for  all 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     101 


10^2 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     103 


104 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     105 


106 


EQllLIBRHM  AND  VKIMKiO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     107 


108 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     109 

practical  clinical  purposes,  especially  in  reference  to  localization, 
it  is  sufficient  to  consider  each  hemisphere  as  divided  into  a  superior 
and  inferior  portion.  The  vermis  has  also  been  subdivided  into 
various  portions,  but  for  our  purposes  it  is  sufficient  to  consider 
the  vermis  to  consist  of  a  superior  and  an  inferior  portion,  since  it  is 
these  portions  of  the  vermis  that  are  supposed  to  contain  within 
them  distinctly  different  functionating  centers. 

The  cortex  of  the  cerebellum  is  composed  of  large  cells  from 
which  nerve-fibres  originate.  Some  of  these  fibre  tracts  are  con- 
nected with  a  central  group  of  cells  within  the  cerebellar  hemis- 
phere known  as  the  dentate  nucleus.  Other  fibre  tracts  coming 
from  either  the  cerebellar  cortex  or  from  the  dentate  nucleus  are 
in  connection  with  either  tli»p  cerebrum,  pons  or  spinal  cord.  The 
inferior  cerebellar  peduncles  or  restiform  bodies  connect  the  an- 


FiG.  26. — Dissection  of  structures  through  which  impulses  producing  vertigo  pass  to  the  posterior  portion 
of  first  and  second  temporal  convolutions. 


terior  border  of  the  cerebellum  with  the  medulla  oblongata.  They 
pass  upward  and  inward  toward  the  vermis  of  the  cerebellum  and 
the  upper  part  of  the  lateral  lobes.  They  consist  chiefly  of  fibres 
which  come  from  the  spinal  cord  and  contain  the  vestibular 
fibres  which  come  from  the  horizontal  semicircular  canals  of  the 
labvrinth. 


110 


EQUILIBRIUM  AND  VER'J  IGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM     111 


m 


EQUILIBRIUM  AND  VERTIGO 


MEDULLA  OBLONGATA,  PONS  AND  CEREBELLUM    113 

The  middle  peduncles,  the  largest  of  the  cerel)ellar  peduncles, 
pass  backward  from  the  pons  toward  the  cerebellum  and  are  found 
to  the  outer  side  of  the  inferior  cerebellar  peduncles.  They  con- 
sist almost  entirely  of  the  transverse  fibres  from  the  ventral  por- 
tion of  the  pons.  These  fibres  connect  the  cerebellum  with  the 
pons,  the  fibres  ending  in  a  group  of  cells  in  the  pons,  on  the  side 
opposite  to  their  origin.  From  here  a  new  system  starts  and  goes 
to  the  internal  portion  of  the  foot  of  the  cerebral  peduncles  and 
then  into  the  frontal  lobes.  The  middle  cerebellar  peduncles  also 
probably  carry  the  vestibular  fibres  from  the  labyrinth  which 
originate  in  the  vertical  semicircular  canals. 

The  superior  cerebellar  peduncles  are  small  bands  of  white  mat- 
ter w^hich  emerge  from  the  anterior  border  of  the  cerebellum,  run 
forward  and  inward  at  the  sides  of  the  upper  part  of  the  IV  ven- 
tricle, to  the  upper  part  of  the  pons.  Each  superior  cerebellar 
peduncle  connects  the  cerebellar  hemisphere  of  that  side  with  the 
cerebral  hemisphere  of  the  opposite  side,  the  fibres  decussating  in 
the  upper  portion  of  the  pons,  then  entering  the  cells  of  the  red 
nucleus  in  the  posterior  portion  of  the  cerebral  crura.  From  here 
new  groups  of  fibres  arise  and  enter  the  optic  thalamus  from  which 
they  are  distributed  to  the  lateral  portions  of  the  cerebral 
hemisphere  of  that  side. 

We  do  not  possess  correct  knowledge  of  the  function  of  all  the 
fibres  of  the  different  cerebellar  peduncles.  We  do  know,  how- 
ever, that  the  inferior  cerebellar  peduncle  is  concerned  with  the 
synergic  movement  of  the  limbs,  and  also  contains  vestibular  fibres 
from  the  horizontal  semicircular  canal.  The  middle  cerebellar 
peduncles  are  probably  concerned  with  synergy  of  the  trunk,  and 
contain  the  vestibular  fibres  from  the  vertical  semicircular  canals 
of  the  labyrinth,  while  the  superior  cerebellar  peduncles  are  prob- 
ably concerned  with  co-ordinating  the  motor  and  sensory  impulses 
of  the  cerebral  cortex  with  those  of  the  cerebellum. 


CHAPTER  XIII 

CEREBELLAR  LOCALIZATION 

The  views  on  cerebellar  localization  and  cerebellar  symptoma- 
tology presented  in  this  chapter  have  been  adapted  from  the  local- 
ization advanced  by  Mills  and  Weisenburg.  It  must  be  understood 
that  the  scheme  of  localization  in  the  human  cerebellar  cortex 
advanced  by  them  is  only  tentative  and  in  some  particulars  is 
merely  suggestive. 

The  cerebellum  is  essentially  a  motor  organ  and  is  concerned 
with  supplying  the  necessary  synergy  for  bodily  movements.  As 
bodily  movements  are  as  a  rule  complex  movements,  it  is  evident 
that  no  one  centre  or  single  area  representing  any  one  part  could 
well  represent  the  entire  bodily  movement  in  question.  The  eyes 
may  move  to  the  right  or  left  or  up  or  down,  without  association 
of  any  other  movements,  but  on  the  other  hand,  the  eyes  may  move 
synergically  with  the  head  or  with  the  head  and  trunk  or  w^ith  the 
head  and  trunk  and  limbs.  Similarly  the  trunk  may  be  bent  for- 
ward or  backward,  twisted  to  the  right  or  left,  with  little  or  no 
association  with  movements  of  the  extremities.  Such  compara- 
tively simple  trunkal  movements,  however,  are  not  the  rule  in  daily 
life.  The  role  played  by  the  cerebellum  has  its  best  exemplifi- 
cation in  such  acts  as  advancing  and  retiring  in  the  erect  position 
or  in  the  performance  of  complex  movements  when  standing,  as  in 
fencing,  boxing  or  public  speaking;  or  in  driving  and  regulating 
a  rapidly  moving  automobile ;  or  in  any  highly  trained  movements 
such  as  are  exhibited  in  a  series  ascending  in  complexity  and 
rapidity  of  association  from  a  game  of  tennis  or  baseball  to  the 
handling  of  an  aeroplane. 

Xo  one  area  in  the  cerebellum  could  represent  such  a  complexly 
associated  neuromechanism.  In  other  words,  cerebellar  localization 
is  compound  in  its  cortical  representation.  A  composite,  however, 
lias  always  witliin  it  factors  or  elements  wliich  can  to  a  less  or 

114 


CEREBELLAR  LOCALIZATION  115 

greater  extent  be  separated  from  the  entire  mass.  In  the  human 
cerebellum  we  must  be  able  to  recognize  a  cortical  representation 
for  synergic  movements  whether  simple  or  complex.  Each  simple 
synergic  movement  has,  however,  its  special  cortical  representa- 
tion. Cerebellar  cortical  representation  is  analogous  to  cerebral 
cortical  localization,  but  only  analogous  and  not  similar.  In  the 
cerebral  cortex  each  individual  movement  is  definitely  represented 
by  a  group  of  cells,  which,  under  the  control  of  the  will,  initiates 
the  necessary  energy  that  results  in  the  contraction  of  the  particular 
muscle  group  necessary  for  that  movement.  Such  a  cortical  area 
supplies  energy  '*in  the  rough" — energy  pure  and  simple  and  un- 
guided.  In  order  to  carry  out  a  definite  movement  of  a  limb  or 
any  portion  of  the  body,  more  than  one  muscle  has  to  contract  at  the 
same  time  to  produce  the  desired  result.  The  muscles  concerned 
in  the  particular  movement  derive  their  energy  from  the  cerebral 
cortex ;  this  energy,  however,  must  be  guided  or  synergized  in  order 
that  this  movement  be  performed  with,  any  degree  of  precision  and 
nicety.     Such  a  guide  for  this  energy  is  furnished  by  the  cerebellum. 

The  cerebellum  therefore  is  not  concerned  with  the  contraction 
of  any  one  muscle  but  rather  with  groups  of  muscles,  which,  in 
turn,  are  concerned  in  certain  definite  movements.  Let  us  take, 
for  example,  the  shoulder  joint.  There  is  a  certain  group  of 
muscles  which  always  act  when  the  upper  extremity  moves  out- 
w^ard.  There  is  likewise  another  group  of  muscles  which  act  when 
the  extremity  moves  inward,  and  similarly  a  group  of  muscles  for 
moving  it  upward,  and  still  another  for  moving  it  downward. 
While  each  one  of  these  movements  is  individually  represented 
in  the  cerebral  cortex,  in  the  cerebellar  cortex  all  these  movements 
are  represented  in  an  outward-pointing  centre,  an  inward-pointing 
centre,  an  upward-pointing  centre  and  a  downward-pointing  centre. 

When  an  individual  desires  to  move  his  upper  extremity  down- 
w^ard  and  touch  a  certain  point,  the  cerebral  cortex  supplies  the 
energy  necessary  for  the  muscles  to  move  the  arm  downward.  This 
alone,  however,  w^hile  supplying  the  energy  necessary  for  the  move- 
ment would  not  result  in  a  very  precise  movement.  The  necessary 
precision  is  furnished  by  the  cerebellum.    In  this  particular  move- 


116  EQUILIBRIUM  AND  VERTIGO 

ment  the  centres  concerned  would  be  the  outward-pointing  centre 
and  the  inward-pointing  centre  for  that  extremity.  These  two 
centres  would  act  against  each  other  so  that  the  arm  would  be 
brought  down  in  a  perfectly  straight  line.  Should  the  individual 
desire  to  touch  a  certain  point  with  his  right  upper  extremity, 


Fissure       \ 


Great"  Horizontal 
Fissure 

Fig.  30. — Cerebellar  localization;  zones  and  centres  of  the  superior  surface  of  the  cerebellum. 


Zres<t  HorizoTital 
Fi'ssu 


fissurf 


Post  Pxjram 
Fissure 


Fig.  31. — Cerebellar  localization;  zones  and  centres  of  the  inferior  surface  of  the  cerebellum. 


moving  it  from  Side  to  side,  the  cerebellar  control  would  be  mani- 
fested by  a  functioning  of  the  upward-pointing  centre  and  down- 
ward-pointing centre  for  that  extremity. 

Unfortunately  the  exact  location  of  the  centres  for  the  different 


CEREBELLAR  LOCALIZATION  117 

simple  movements  of  the  various  joints  is  not  yet  known.  Cere- 
bellar cortical  representation  is  believed  to  be  homolateral,  the 
right  side  of  the  cerebellum  supplying  synergy  for  the  right  side 
of  the  body.  Based  on  studies  of  cerebellar  embryology,  compara- 
tive anatomy,  experimentation  and  clinical  pathology,  a  tentative 
scheme  of  cerebellar  localization  was  worked  out  as  shown  in 
figures  30  and  31.  In  connection  with  this  work  on  neuro-otology, 
we  take  advantage  of  this  scheme  in  attempting  to  throw  light  on 
the  location  of  cerebellar  lesions.  The  outward-pointing  centre 
for  the  shoulder  is  believed  to  be  located  in  the  anterior  portion  of 
the  quadrangular  lobes,  whereas  the  centre  for  the  inward -pointing, 
of  tlie  right  shoulder  is  located  in  the  posterior  portion  of  the 
quadrangular  lobe,  of  the  right  cerebellar  hemisphere. 

In  this  connection  we  must  note  that  Barany  conducted  experi- 
ments on  the  living  human  being,  on  whom  extensive  cerebellar 
decompressions  had  been  done.  By  means  of  ethyl  chloride  he 
chilled  certain  areas  of  the  cerebellar  cortex  and  then  by  vestibular 
stimulation  noticed  whether  there  was  any  deviation  from  the  nor- 
mal past-pointing.  When  such  ear-stimulation  was  applied  that  the 
right  arm  should  past-point  to  the  right,  lie  noted  that  such  past- 
pointing  was  absent  when  he  had  chilled  the  superior  and  inferior 
semilunar  lobes  of  the  right  cerebellar  hemisphere.  He  further 
noted  that  when  he  chilled  the  biventral  lobe  of  the  right  cerebellar 
hemisphere,  the  right  arm  could  not  be  made  to , past-point  inward 
after  such  stimulation  that  should  make  it  past-point  inward.  He 
therefore  concluded  that  the  outward  pointing  centre  for  the 
shoulder  joint  is  located  in  the  semilunar  lobe  and  that  the  inward 
pointing  centre  of  the  shoulder  is  located  in  the  biventral  lobe. 

From  a  clinico-pathologic  standpoint,  when  stimulation,  ^0"* 
matter  how  applied,  fails  to  produce  a  past-pointing — let  us  say 
of  the  right  arm  to  the  right — it 'would  "suggest  some  disturbance 
of  the  outw^ard-pointing  centi%*in  the  right  cerebellar  hemisphere. 
Likewise  when  stimulation  fails  to  make  the  right  arm  past-point 
to  the  left,  'it  would  suggest  a  disturbance  of  the  inward-pointing 
centre  of  the  right  cerebellar  hemisphere. 

Clinically  speaking,  the  thought  to  bear  in  mind  is  that  the 


118  EQUILIBRIUM  AND  VERTIGO 

cerebellum  is  concerned  with  synergy  for  all  the  movements  of 
the  body  and  whatever  symptoms  may  be  present,  such  as  hypor- 
metry,  adiadokokinesis  or  tremor,  all  result  from  loss  of  synergy. 

The  vermis  of  the  cerebellum  governs  the  pelvic  girdle  muscles 
and  a  lesion  of  the  vermis  is  suggested  if,  for  example,  on  pushing 
the  patient  backward  the  pelvis  does  not  move  forward  as  it  should 
normally.  In  such  cases  the  patient  may  fall  directly  backward 
like  a  broomstick. 

In  presenting  the  symptomatology^  of  lesions  of  special  por- 
tions of  the  cerebellum  and  its  connections,  we  first  discuss  lesions 
confined  strictly  to  the  cerebellum;  second,  lesions  implicating  the 
superior,  middle  and  inferior  cerebellar  peduncles ;  third,  lesions 
of  the  cerebello-pontile  angle ;  and,  last,  lesions  invading  the  cere- 
bello-pontile  angle  secondarily. 

We  desire  to  emphasize  that,  to  make  an  accurate  diagnosis 
of  a  cerebellar  lesion,  it  is  necessary  to  take  into  consideration 
not  only  the  cerebellar  symptoms,  but  all  other  symptoms.  We 
have  been  repeatedly  impressed  with  this  fact  since  our  attention 
has  been  more  especially  directed  to  this  subject.  Often  we  have 
made  a  diagnosis  of  a  lesion  of  the  labyrinth  only  to  find  the  cere- 
bellum implicated,  and  vice  versa ;  again  we  have  diagnosed  cere- 
bello-pontile-angle  tumors  only  to  find  that  the  angle  was  second- 
arily invaded  by  a  lesion  growing  from  the  cerebellum.  It  has  not 
been  infrequent  to  diagnose  lesions  of  the  cerebellum  when  the 
tumor  has  been  in  the  third  ventricle  and  has  involved  the  superior 
cerebellar  ]ieduncles  secondarily. 


Diagnosis  of  Lesions  Strictly  Confined  to  the  Cerebellum. 

In  accordance  with  our  views  of  cerebellar  function,  lesions  of 
the  cerebellum  itself  cause  more  strictly  limited  symptoms  than 
those  which  invade  any  of  the  peduncles.  Most  tumors  of  the 
cerebellum  are  gliomatous  and  are  of  slow  growth.  The  majority 
tend  to  invade  the  middle  rather  than  the  outer  portions  of  the 
cerebellum,  and  as  a  consequence,  the  vermis  is  nearly  always  in- 


CEREBELLAR  LOCALIZATION  119 

volved  wholly  or  in  part,  in  addition  to  one  of  the  lateral  lobes.  We 
believe  that  in  the  superior  vermis  are  centred  the  synergic  move- 
ments of  the  upper  trunk  or  shoulder  girdle  and  in  the  inferior 
vermis  the  movements  of  the  lower  trunk  or  pelvic  girdle.  As  a 
consequence  there  will  always  be  in  such  lesions,  in  addition  to 
disturbances  in  the  movement  of  one  or  both  limbs,  alterations 
in  the  station  and  gait.  In  cases  in  which  the  vermis  is  impli- 
cated, the  staggering  is  mainly  forward  or  backward,  rather  than 
to  one  side,  and  of  such  cases,  it  is  more  marked  in  the  shoulder 
girdle  type.  In  our  experience,  if  in  addition  to  the  involvement 
of  the  vermis,  the  lateral  lobes  are  implicated,  the  sway  of  the 
trunk  is  to  the  side  of  the  lesion,  although  it  must  not  be  forgotten 
that  in  a  progressive  cerebellar  disease  the  patient  may  learn,  for 
example,  to  go  voluntarily  to  the  left  to  offset  his  staggering  to 
the  right. 

In  those  instances  in  which  the  lateral  lobes  alone  are  impli- 
cated, the  asynergic  movements  are  present  only  in  the  limbs  of  the 
involved  side;  if  in  the  superior  lobe,  in  the  upper  limb,  and  if  in 
the  inferior  lobe,  in  the  lower  limb.  By  direct  stimulation  of  the 
vestibular  apparatus  by  the  turning  and  caloric  tests  it  is  possible 
to  obtain,  for  example,  a  total  lack  of  outward  pointing  or  inward 
pointing;  this  is  not  so  readily  demonstrated  by  other  tests. 

General  Symptoms. — The  presence  of  cranial  nerve  symptoms, 
as  of  the  VII,  VI,  V,  IX,  X  or  XII,  indicates  that  the  lesion  is 
extracerebellar.  Involvement  of  the  motor  fibres,  with  paresis 
of  the  limbs,  increased  reflexes  and  Babinski,  indicates  that  there 
is  pressure  on  the  motor  apparatus  and  should  not  be  expected 
in  lesions  strictly  confined  to  the  cerebellum,  except  in  those  cases 
in  which  the  lesion  is  very  large.  As  a  rule,  motor  involvement 
indicates  a  pontile  lesion  or  a  lesion  in  the  angle  pressing  on  the 
pons.  Headache,  nausea,  vomiting  and  choked  disc  are,  of  course, 
early  manifestations,  but  only  in  those  instances  in  which  there 
is  interruption  in  the  flow  of  the  cerebro-spinal  fluid ;  they  generally 
indicate  a  lesion  either  in  the  crus  or  pons  pressing  on  the  aque- 
duct of  Sylvius. 


120  EQUILIBRIUM  AND  VERTIGO 

Lesions  of  the  Cerebellar  Peduncles 

We  possess  little  definite  knowledge  of  the  functions  of  the 
fibres  in  the  cerebellar  peduncles.  It  is  supposed  that  the  inferior 
and  middle  peduncles  transmit  impulses  to  the  cerebellum,  and 
that  the  superior  jjeduncle  transmits  impulses  from  this  organ.  It 
is  probable,  however,  that  all  the  peduncles  transmit  impulses  in 
both  directions.  It  is  also  probable  that  the  inferior  peduncles  are 
concerned  chiefly  with  synergic  movement  of  the  lower  limbs,  and 
to  a  lesser  degree  of  the  upper  limbs,  the  middle  peduncle  with 
the  synergic  movement  of  the  trunk  and  head,  and  that  the  superior 
peduncles  are  mainly  concerned  with  tlie  association  of  cerebral 
with  cerebellar  functions.  All  this,  however,  is  theory,  based 
somewhat  on  anatomic  and  physiologic  facts,  but  not  as  yet  sup- 
ported by  pathologic  and  clinical  data. 

In  the  literature  there  are  a  few  instances  of  lesions  confined 
more  or  less  to  one  of  the  peduncles,^  but  it  cannot  be  said  that  our 
clinical  exjoerience  is  such  that  we  can  ditferentiate  the  asynergy 
resulting  from  lesions  of  the  superior  from  those  of  the  middle  or 
inferior  peduncles.  From  our  present  knowledge  all  we  can  say 
is  that  lesions  strictly  confined  to  any  of  the  peduncles  cause 
asynergic  symptoms  in  all  parts  of  the  body  and  as  a  consequence 
we  are  compelled  to  make  the  diagnosis  not  on  the  cerebellar  symp- 
toms but  on  those  associated  with  them. 

There  are  instances  in  the  literature  in  which  so-called  turiiing 
or  rolling  movements  have  been  recorded,  in  tumors  of  the  middle 
and  of  the  inferior  peduncles,  either  toward  or  away  from  the 
side  of  the  lesion;  but  these  cases  are  not  definite  and  cannot  be 
relied  on.  There  is,  however,  this  difference  in  the  cerebellar 
symptomatology  of  the  ditTerent  peduncles.  Because  of  the  ana- 
tomic relation  of  the  superior  peduncles,  lesions  of  this  part  usually 
invade  both  sides,  the  cerebellar  symptoms  being  present  all  over 
the  body,  and  only  rarely,  as  in  a  case  reported  by  Mills  in  which 
there  was  thrombosis  of  the  superior  cerebellar  artery,  is  the 
asynergy  limited  to  the  limbs  on  one  side.  As  the  middle  cerebellar 
peduncles    are   more   widely    separated,    such    lesions    are    often 


CEREBELLAR  LOCALIZATION  Ul 

unilateral,  and  tumors  implicating  the  inferior  cerebellar  peduncle 
are  almost  always  one-sided. 


Lesions  of  the  Cekebello-pontile  Angle 

The  diagnosis  of  tumor  in  this  area  as  a  rule  is  not  difficult. 
We  have  encountered  cases,  however,  in  which  such  diagnosis 
had  been  made,  only  to  find  that  this  angle  was  invaded  secondarily 
by  tumors  growing  from  the  cerebellum  and  more  rarely  from  the 
pons.  The  dilferential  diagnosis  is  important  trom  the  surgical 
standpoint,  for  it  is  readily  seen  that  tumors  growing  from  the 
pons  or  cerebellum  olfer  little  hope  for  surgical  removal. 

Tumors  growing  in  this  angle  are  usually  fibromatous  and 
more  rarely  fibrosarcoma.  We  have  encountered  a  number  of 
cysts,  but  these  are  generally  parts  of  gliomatous  tumors  growing 
from  the  cerebellum.  Most  tumors  grow  from  the  VIII  and 
more  rarely  from  the  A^ll,  V,  or  VI  cranial  nerves  respectively. 
The  first  symptoms  are  usually  referred  to  the  cranial  nerve  from 
wJiich  the  tumor  grows  and  in  the  course  of  time  the  other  nerves 
m  the  angle  become  implicated.  Of  course,  the  symptoms  depend 
on  the  size  of  the  grow^th.  In  small  tumors  no  pressure  is  exerted 
on  either  the  pons  or  cerebellum.  In  a  well-developed  case,  besides 
the  cranial  nerve  symptoms,  because  of  the  pressure  on  the  pons, 
there  are  motor  symptoms  on  the  opposite  side  of  the  body  and 
more  rarely  sensory  phenomena. 

Because  of  the  pressure  on  the  anterior  part  of  the  cerebellum, 
both  the  superior  and  inferior  surfaces  are  involved,  this  causing 
cerebellar  asynergy  of  both  limbs  of  the  same  side.  In  cases  in 
which  the  angle  is  invaded  secondarily  from  the  cerebellum  or  from 
the  pons,  the  cerebellar  symptoms  are  always  much  more  marked, 
and  it  is  because  we  have  not  been  sufficiently  careful  in  the  differ- 
entiation of  the  cerebellar  phenomena  that  errors  in  diagnosis  have 
arisen. 


CHAPTER  XIV 

TRACTS  OF  THE  AUDITORY  APPARATUS  AND  OF  THE 
VESTIBULAR  APPARATUS 

Having  up  to  this  chapter  discussed  the  anatomy  and  physi- 
ology of  the  labyrinth,  the  Vlii  Nerve,  the  medulla  oblongata, 
the  pons  and  the  cerebellum,  we  now  consider  those  tracts  or 
paths  which,  as  it  were,  link  them  together.  It  is  generally  known 
that  there  must  exist  a  definite  nerve-pathway  between  the  cochlea 
and  the  cerebral  cortex  in  order  that  stimulation  of  the  cochlea  by 
sound-waves  shall  produce  the  conscious  sensation  of  hearing. 
.Similarly,  if  stimulation  of  the  semicircular  canals  causes  the  eyes 
to  move,  it  is  evident  that  there  must  be  a  nerve-path  between 
the  ear  and  the  eye  muscles.  Further,  if  stimulation  of  the  semi- 
-circular  canals  produces  a  conscious  sensation  which  we  call 
vertigo,  it  is  evident  that  there  must  be  a  nerve-path  between 
the  ear  and  that  portion  of  the  cerebral  cortex  which  receives  this 
impulse.  The  course  of  the  auditory  fibres  has  been  histologically 
demonstrated  by  many  investigators  so  that  the  pathways  along 
which  sound  impulses  travel  are  more  or  less  known;  not  so  with 
the  vestibular  apparatus.  The  recognition  of  the  ear  as  the  chief 
•equilibratory  organ  is  so  recent  that  most  of  its  intracranial  path- 
ways are  still  undetermined.  On  the  basis  of  over  700  clinical 
cases,  including  a  considerable  number  of  operations  and  autopsies, 
we  have  come  to  certain  conclusions  in  regard  to  these  pathways, 
«ome  of  them  definite  and  others  needing  further  analysis. 

Ramon  y  Cajal  has  shown  histologically  that  fibres  from  the 
vestibular  portion  of  the  VIII  Xerve  enter  Deiters'  nucleus  and 
continue  through  the  inferior  cerebellar  peduncle  into  the  cerebel- 
lum itself.  This  path  is  generally  recognized  and  accepted.  Our 
observations  up  to  the  present  time  have  suggested  in  addition 
Ihe  following: 

122 


TRAC'J^  OF  THE  AUDITORY  APPARATUS  123 

(1)  After  entering  the  brain-stem  the  iibres  from  tlje  hori- 
zontal semicircular  canal  have  a  distinct  and  separate  pathway 
from  the  fibres  from  the  vertical  semicircular  canals. 

(2)  The  fibres  from  the  vertical  semicircular  canals  ascend  into 
the  pons. 

(3)  The  fibres  already  demonstrated  by  Cajal  are  those  from 
the  horizontal  semicircular  canal  exclusively. 

(4)  The  fibres  conveying  impulses  to  the  eyes  are  distinct  and 
separate  from  those  conveying  the  impulses  producing  vertigo. 

(5)  The  fibres  conveying  the  impulses  producing  vertigo  go 
through  the  cerebellum  en  route  to  the  cerebrum. 

Our  reasons  for  these  conclusions  are  as  follows :  In  38  cases 
in  which  the  labyrinths  and  the  VIII  Nerves  were  normal  and  the 
horizontal  canal  gave  normal  reactions,  the  vertical  canals  failed 
to  produce  the  well-known  responses.  The  following  phenomena 
appeared:  On  stimulation  of  the  horizontal  canal  there  was  ob- 
tained a  normal  nystagmus,  vertigo  and  past-pointing;  on  stimu- 
lation of  the  vertical  canals,  however,  there  was  no  reaction  or  only 
a  partial  reaction.  In  some  cases  there  was  produced  no  nystag- 
mus, no  vertigo,  no  past-pointing,  no  falling,  no  nausea^ — in  other 
words,  all  responses  failed;  in  other  cases  some  of  the  responses 
appeared  and  others  did  not.  In  some  cases  the  vertical  canals  of 
each  side  failed  to  respond,  whereas  the  horizontal  canal  of  each 
side  responded  perfectly.  It  must  be  borne  in  mind  that  in  all  of 
these  cases  the  labyrinths  themselves  were  nonnal.  In  other 
words,  the  vertical  semicircular  canals  themselves  »were  function- 
ing perfectly  and  yet  they  failed  to  produce  normal  responses.  In 
all  these  cases  the  VIII  Nerves  also  were  normal.  If,  therefore, 
the  labyrinths  and  VIII  Nerves  were  normal  and  yet  stimulation 
of  the  vertical  canals  failed  to  produce  normal  responses,  it  is- 
evident  that  there  is  a  central  differentiation  of  the  fibres  from 
the  horizontal  canal  and  of  the  fibres  from  the  vertical  canals. 
Naturally  this  depends  upon  positive  proof  that  the  labyrinth  and 
VIII  Nerves  were  normal ;  this  is  shown  by  the  following  facts : 

(1)  Perfect  hearing.  This  rendered  it  extremely  improbable 
that  there  was  any  destruction  of  the  vertical  semicircular  canals- 


124  EQUILIBRIUM  AND  VERTIGO 

themselves  alone,  leaving  the  horizontal  canal  and  the  cochlea  en- 
tirely intact.  It  is  similarly  improbable,  especially  in  so  large  a 
number  of  cases,  that  within  the  \'II1  Nerve  those  particular  fibres 
from  the  vertical  semicircular  canals  were  involved,  whereas  the 
fibres  from  the  horizontal  canal  and  the  fibres  from  the  cochlea 
were  absolutely  intact. 

(2)  In  each  of  these  cases  there  was  other  corroborative  evi- 
dence of  involvement  of  the  brain-stem. 

(3)  In  five  cases  stimulation  of  the  vertical  canals  produced 
no  nystagmus,  no  vertigo,  no  past-pointing  and  no  falling,  and  yet 
violent  projectile  vomiting  occurred.  It  is  evident  that  the  vertical 
canals  themselves  and  the  fibres  from  the  vertical  canals  in  tlie 
YIll  Nerve  were  functionating — showing,  as  they  did,  even  a 
hyperactive  response  of  the  X  nucleus  to  stimulation  of  the  canals. 
This  of  course  makes  it  absolutely  conclusive  that  the  vertical 
canals  themselves  were  functionating  and  that  the  pathway  was 
intact  at  least  from  the  vertical  canals  to  the  X  nucleus  in  the 
medulla  oblongata.  It  follows,  therefore,  that  there  is  necessarily 
a  central  differentiation  of  the  fibres  from  the  different  canals. 
For  detailed  description  of  cases  of  this  class  and  their  analysis 
the  reader  is  referred  to  pages  340,  347,  358,  364,  373,  390,  398,  407, 
412  and  430. 

In  one  of  these  cases  (Mrs.  D.,  given  in  detail  on  page  340)  the 
vertical  canals  of  the  right  ear  produced  no  response  on  stimu- 
lation although  the  lal^yrinth  itself,  as  well  as  the  VIII  Nerve,  was 
normal.  Autopsy  with  histological  examination  by  Spiller  showed 
a  glioma  involving  the  upper  portion  of  the  pons,  whereas  the 
lower  half  of  the  pons  and  the  medulla  oblongata  were  normal. 
This  proves  that  the  vertical  canals  fibres  ascend  into  the  pons 
at  least  as  far  as  the  location  of  this  lesion  in  the  upper  part  of  the 
pons.  Another  case,  declared  by  Weisenburg  to  be  a  classical  case 
of  lesion  in  the  right  side  of  the  pons  posteriorly  in  the  region  of 
the  middle  cerebellar  peduncle,  also  failed  in  all  responses  on 
stimulation  of  the  right  vertical  canals.  The  horizontal  canal  and 
all  the  canals  of  the  left  ear  gave  normal  responses.  This  suggests 
that  the  vertical  canals  fibres  were  involved  by  this  lesion  in  the 


TRACT  OF  THE  AUDITORY  APPARATUS     125 

pons  on  the  rig-lit  side.  Cases  in  which  autopsies  have  shown  the 
following  lesions — cerebello-pontile  angle  tumors  pressing  against 
the  pons,  intracerebellar  tumors  invading  the  pons,  abscess  of  the 
IV  ventricle  with  pressure  on  the  pons  and  internal  hydrocephalus 
with  pressure  within  the  IV  ventricle  ui)on  the  pons — in  all  of  these 
cases  stimulation  of  the  vertical  semicircular  canals  produced  no 
reaction,  w^hereas  the  horizontal  canals  gave  normal  responses. 

If,  as  suggested  above,  lesions  involving  the  pons  cause  a  block 
in  the  tracts  from  the  vertical  semicircular  canals,  but  leave  the 
tracts  from  the  horizontal  canal  intact,  and  if,  furthermore,  in 
these  cases  the  medulla  oblongata  is  proven  intact,  the  logical  con- 
clusion is  that  the  fibres  demonstrated  by  Cajal  in  the  medulla 
oblongata  and  inferior  cerebellar  peduncle  must  be  the  fibres  from 
the  horizontal  semicircular  canal  exclusively.  A  case  (Mr.  L., 
given  in  detail  on  page  332)  confirms  this  viewpoint.  Spiller  says 
that  this  patient  presented  the  clean-cut  symptom-complex  gen- 
erally accepted  neurologically  as  thrombosis  of  the  posterior  in- 
ferior cerebellar  artery.  Spiller,  H.  M.  Thomas,  Hun  and  Van 
Gieson  have  demonstrated  similar  cases  histologically;  they  show 
softening  in  the  medulla  oblongata  in  the  region  of  the  inferior 
cerebellar  peduncle.  In  this  case  the  lesion  suggested  is  in  the 
right  inferior  cerebellar  peduncle.  Ear  examination  showed  the 
following:  The  left  horizontal  canal,  the  left  vertical  canals,  and 
the  right  vertical  canals  all  produced  normal  responses  in  nystag- 
mus, vertigo,  past-pointing  and  falling;  the  right  horizontal  canal 
produced  a  normal  nystagmus,  but  there  was  a  striking  impairment 
of  vertigo  and  past-pointing.  This  suggests,  therefore,  that  the 
horizontal  canal  fibres  responsible  for  vertigo  are  involved  in  this 
lesion  in  the  inferior  cerebellar  peduncle.  It  also  suggests  that  as 
the  vertical  canals  of  the  same  ear  gave  normal  responses,  the 
vertical  canals  fibres  are  not  in  the  inferior  cerebellar  peduncle. 
This  patient  has  been  examined  at  intervals  for  over  two  years 
and  on  each  occasion  invariably  shows  the  same  clean-cut 
phenomena. 

The  following  cases  would  seem  to  suggest  that  the  horizontal 
canal  fibres  are  externally  located  in  the  brain-stem  and  that  the 


126  I<:QriLIBRIUM  AND  VERTIGO 

vertical  canals  fibres  are  mesially  located.  One  case  showed  a  com- 
plete deafness  in  the  left  ear  and  no  responses  whatever  from  either 
the  horizontal  canal  or  from  the  vertical  canals.  The  right  ear 
showed  normal  hearing,  normal  responses  from  the  right  horizontal 
canal,  but  no  responses  whatever  from  the  right  vertical  canals.  Au- 
topsy showed  tumor  of  left  cerebellar  hemisphere,  in  the  biventral 
lobe,  involving  the  \T1I  Nerve  in  the  left  cerebello-pontile  angle; 
the  tumor  was  pressing  against  the  brain-stem.  This  suggests  that 
the  pressure  on  the  left  side  was  sufficient  to  involve  tlie  right 
vertical  canals  fibres,  which  wouhl  therefore  seem  to  be  nearer  the 
median  line,  and  that  the  horizontal  canal  fibres  of  the  right  side 
which  were  not  involved  by  this  pressure  would  seem  to  be  more 
externally  located,  beyond  the  influence  of  the  pressure.  A  similar 
case  (Mrs.  R.,  page  412)  showed  com])lete  deafness  of  the  left  ear 
and  an  absence  of  responses  from  the  left  horizontal  and  the  left 
vertical  canals.  On  the  right  side  there  were  no  responses  from  the 
vertical  canals,  whereas  the  horizontal  canal  gave  normal  reactions. 
It  will  be  noted  that  these  phenomena  are  identical  with  those 
appearing  in  the  case  just  quoted.  A  decompression  operation  was 
done  by  Dr.  J.  Chalmers  Da  Costa ;  one  week  later  another  examina- 
tion showed  that  not  only  the  horizontal  canal  fibres  of  the  right 
side  reacted  normally,  but  also  the  vertical  canals  fibres  of  the  right 
side.  This  rather  strikingly  suggests  that  the  pressure  on  the  right 
vertical  canals  fibres  had  been  relieved  by  the  decompression. 

That  the  fibres  conveying  impulses  to  the  eyes,  resulting  in 
nystagmus,  are  distinct  and  separate  from  those  conveying  im- 
pulses to  the  cerebral  cortex,  producing  vertigo,  is  borne  out  by  the 
following  cases:  (1)  Twenty-four  cases  of  spontaneous  nystagmus, 
unassociated  with  any  vertigo  whatever;  (2)  innumerable  cases  of 
spontaneous  vertigo,  unassociated  at  any  time  with  nystagmus; 
(3)  six  patients  who  after  ear-stimulation  showed  a  normal  nystag- 
mus both  in  amplitude  and  duration,  but  no  vertigo;  (4)  a  patient 
who  after  ear-stimulation  had  no  nystagmus  whatever  and  yet  ex- 
perienced normal  vertigo.  The  normal  vertigo  was  proven  by  the 
exhibition  of  normal  past-pointing  and  falling. 


TRACT  OF  THE  AUDITORY  APPARATUS     127 

That  the  fibres  conveying  the  impulses  i^roducing  vertigo  go 
through  the  cerebellum  en  route  to  the  cerebrum,  is  made  liighly 
probable  in  that  without  exception  all  of  our  cases  in  which  opera- 
tion or  autopsy  has  demonstrated  a  cerebellar  lesion,  have  shown 
vertigo  to  be  markedly  subnormal  or  absent  after  ear-stimulation. 

Summarizing,  we  are  confident  that  the  fibres  from  the  hori- 
zontal canal  and  the  fibres  from  the  vertical  canals  have  separate 
pathways  in  the  brain-stem.  This  is  absolute.  That  the  horizontal 
canal  fibres  are  confined  to  the  medulla  oblongata  and  enter  the 
cerebellum  throuph  the  inferior  cerebellar  peduncle,  and  that  the 
vertical  canals  fibres  ascend  into  the  pons  and  enter  the  cerebellum 
through  the  middle  peduncle,  we  believe  to  be  highly  probable; 
but  we  feel  that  the  evidence  to  date  is  not  sufficiently  large  to 
make  absolute  the  exact  course  of  the  fibres.  Therefore  the  tracts 
that  we  are  about  to  present  are  of  course  not  to  be  regarded  as 
final.  They  do,  however,  represent  the  logical  conclusions  from 
our  evidence  to  date.  Furthermore,  when  used  as  a  working 
basis  for  the  examination  of  patients,  this  conception  of  the  ves- 
tibular pathways  has  furnished  diagnostic  data  which  have  proven 
surprisingly  reliable.  Further  observation  by  ourselves  and 
others  may  no  doubt  modify  or  change  our  conception  of  the  exact 
course  of  the  fibres.  In  the  main  essentials,  however,  these  tracts 
may  be  regarded  as  accurate  and  in  presenting  them  we  will  speak 
dogmatically  for  the  sake  of  clearness. 

Tracts  in  Detail 

From  the  various  end-organs  within  the  labyrinth,  namely,  the 
Corti's  organ  of  the  cochlea,  the  maculae  of  the  utricle  and  saccule, 
and  the  cristae  of  the  three  semicircular  canals,  nerve-fibres  enter 
the  internal  auditory  meatus,  where  they  all  unite  in  one  common 
bundle  to  form  the  VIII  Nerve.  At  the  point  of  entrance  of  the 
VIII  Nerve  into  the  medulla  oblongata,  the  nerve-fibres  again 
divide  into  two  main  trunks,  namely,  the  auditory  and  vestibular 
portions.  It  is  generally  recognized  that  the  auditory  portion  in 
turn  divides  into  two  separate  paths,  an  anterior  and  a  posterior. 


128  EQUILIBRIUM  AND  VERTIGO 

Our  observation  which  so  far  as  we  know  is  new,  is  that  the  ves- 
tibular branch  in  a  similar  way  divides  into  two  distinct  paths. 
One  path  consists  of  the  fibres  from  the  horizontal  canal;  the  other 
path  consists  of  the  fibres  from  the  vertical  canals  (Fig.  32). 
Summarizing  then,  the  VIII  Nerve  at  its  entrance  to  the  medulla 
oblongata  divides  as  follows:  (1)  Auditory,  which  divides  into  (a) 
anterior  tract,  and  {h)  posterior  tract.  (2)  Vestibular,  which 
divides  into  (a)  horizontal  canal  fibres,  and  (h)  vertical  canals 
fibres. 

The  VIII  Nerve  may  be  likened  to  a  string  which  is  frayed — 
separated  into  its  constituent  strands — at  both  ends.  The  different 
fibres  which  go  to  make  up  the  nerve,  at  one  end  are  connected  with 
the  various  end-organs  within  the  labyrinth,  and  at  the  other  end 
again  separate  to  pursue  their  different  courses. 


Auditory  Fibres 

The  auditory  fibres  begin  in  the  Corti's  organs  of  the  cochlea, 
relay  in  the  spiral  ganglia  in  the  cochlea  and  enter  the  VIII  Nerve. 
At  the  entrance  of  the  VIII  Nerve  into  the  medulla  oblongata,  an 
anterior  branch  runs  mesially  to  the  trapezoid  body  of  the  same 
and  opposite  side,  and  a  posterior  branch  continues  around  the 
posterior  border  of  the  medulla  oblongata,  passing  around  the  in- 
ferior cerebellar  peduncle  and  becoming  the  so-called  acoustic  striae 
in  the  floor  of  the  IV  ventricle.  The  fibres  from  the  acoustic  strise 
then  continue  fonvard  until  tliey  also  enter  the  trapezoid  body  of 
the  same  and  opposite  side.  From  the  trapezoid  body  the  fibres 
continue  to  the  posterior  corpora  quadragemina  and  the  median 
geniculate  body,  from  which  they  pass  to  the  subthalamic  region 
and  continue  by  association  fibres  to  the  temporal  lobe,  in  the  pos- 
terior portion  of  the  first  and  possibly  second  convolutions.  It  is 
most  probable  that  77iost  of  the  auditory  fibres  from  one  ear  go  to 
the  temporal  lobe  of  the  opposite  side;  some  of  the  fibres,  however, 
go  to  the  temporal  lobe  of  the  same  side. 


RIGHT 


LEFT 


CCREB^^ 


1  i     r^ACf    A^Medull/\  /I 


Oblongata 


PONS 


Cochlea 


Posterior 

CANAL 


VIEWED   FROM   IN     FRONT 


Fig.  32. — Pathways  of  fibres  from  cochlea,  horizontal  canal  and  vertical  canals. 


TRACT  OF  THE  AUDITORY  APPARATUS      129 

Vestibular  Fibres 

After  entering  the  medulla  oblongata,  the  vestibular  portion  of 
the  VIII  Nerve  divides  into  two  tracts,  the  fibres  from  the  hori- 
zontal canal  and  the  fibres  from  the  vertical  canals. 

We  now  consider  the  individual  tracts.  Each  tract  is  best  repre- 
sented by  a  "Y"  (Fig.  33).  One  arm  of  the  "Y"  eventually  goes 
to  the  eye-muscl^S;  the  other  arm  goes  to  the- cerebellum.  The 
tract  to  the  eye-musples  constitutes  the  vestibulo-ocular  tract;  im- 
pulses along  this  tract  result  in  nystagmus.  The  tract  to  the  cere- 
bellum is  the  vestibulo-cerebellar  tract;  impulses  along  this  tract 
and  its  further  continuation  to  the  cerebral  cortex  produce  i)ertigo. 

The  horizontal  canal  fibres  (Fig.  34)  begin  in  the  crista  of  the 
horizontal  canal,  relay  in  Scarpa's  ganglion  and  enter  the  bundle 
of  the  VIII  Nerve  in  which  they  enter  the  medulla  oblongata.  These 
fibres  then  pass  through  the  medulla  oblongata  to  the  posterior 
external  portion,  at  which  point  they  enter  Dieters'  nucleus.  It  is 
at  this  point  that  the  t^-act  divides  into  two  paths.  One  path  goes 
through  the  nucleus  triangularis  toward  the  median  line!",  entering 
the  posterior  longitudinal  bundle,  which  is  situated  in  the  median 
line  along  the  posterior  aspect  of  the  medulla  oblongata  and  pons ; 
the  other  path  extends  from  Deiters'  nucleus  to  the  juxtarestiform 
body,  which  is  the  mesial  portion  of  the  inferior  cerebellar  pe- 
duncle, to  the  three  vestibular  nuclei  within  the  cerebellum.  These 
are  the  nucleus  globosus,  the  nucleus  emboliformis  and  the  nucleus 
fastigii. 

Consulting  the  diagrams,  it  will  be  observed  that  this  tract  is 
represented  by  a  *'Y"  and  after  a  series  of  diagrams  of  the  same 
"Y,"  each  diagram  containing  one  more  feature,  the  final  diagram 
shows  that  the  fibres  on  the  one  hand  reach  the  posterior  longi- 
tudinal bundle,  which  in  turn  connects  it  with  the  nuclei  of  the 
ocular  muscles,  and  on  the  other  hand  the  fibres  reach  the  cerebellar 
nuclei. 

Similarly,  in  the  cristas  of  the  vertical  canals — the  superior  and 
posterior — fibres  originate  which  enter  the  VIII  Nerve.  At  the 
entrance  of  the  VIII  Nerve  into  the  medulla  oblongata,  however, 

9 


130 


EQUILIBRIUM  AND  VERTIGO 


Fig.  33. — Consecutive  Beries  of  diagrams;  pathways  of  fibres  from  the  right  horizontal  canal. 


TRACT  OF  THE  AUDITORY  APPARATUS  131 


OEirCRS    N. 


POSTERIOR 
LONGITUDINAL 
BUNDLES 


OeiTERS   NUCLCVS 


DBITERS  N 


POSTHHOH 
LONOITVDfAAL 
BUNOLEi 


CBREBELLAH   q 
NUCUei  qO 

INFEftlOR 
CEREBELLAR 
PEDUNCLE 
DEITEHS  'N. 


tPOSTERIC 
LONeiTU&lNAL 
BUNDLEl 
lEDULLA  tBL0N6Rrk 


Fig.  34. — Continuation  of  consecutive  series  of  diagrams;  pathways  of  fibres  from  the  right  horizontal  canftl. 


13<2  EQUILIBRIUM  AND  VERTIGO 

instead  of  going  directly  backwards  to  Deiters'  nucleus,  these 
fibres  extend  upicard  along  the  brain-stem  in  a  course  external  to 
the  posterior  longitudinal  bundle.  At  a  point  in  the  upper  half  of 
the  pons,  the  exact  location  of  which  is  not  yet  determined  (an 
undetermined  cell  nest)  there  is  also  a  branching  into  two  arms  of 
the  "Y,"  similar  to  the  branching  of  the  horizontal  canal  fibres 
whieh  occurs  at  Deiters'  nucleus. 

One  a(riii  of  this  "Y"  enters  the  posterior  longitudinal  bundle, 
thus  completing  the  afferent  portion  of  the  vestibulo-ocular  tract 
of  the  vertical  canals  fibres.  Impulses  along  this  tract  result  in 
nystagmus.  The  other  arm  of  the  ^'Y"  directly  enters  the  cere- 
bellum through  the  middle  cerebellar  peduncle  and  is  distributed 
to  the  three  cerebellar  jiuel^i — giobosus,  emboliformis  and  fastigii. 
Impulses  along  this  tract  and  its  further  continuation  to  the  cere- 
bral cortex  produce  vertigo. 

Consulting  the  diagrams  (Figs.  35  and  36),  we  notice  that  this 
tract  is  again  represented  by  a  "Y, "  and  after  a  series  of  dia- 
grams of  the  same  "Y,"  each  diagram  containing  an  additional 
feature,  the  final  diagram  shows  that  the  fibres  on  the  one  hand 
reach  the  posterior  longitudinal  bundle,  and  on  the  other  hand  the 
cerebellar  nuclei.  It  will  be  noted  that  these  diagrams  of  the  verti- 
cal canals  tracts  are  represented  as  a  longitudinal  section  of  the 
pons  and  medulla  oblongata.  This  emphasizes  the  point  that  these 
fibres  proceed  upivard  in  the  brain-stem  before  dividing  into  their 
two  separate  paths. 

If  a  cross-section  were  made  of  the  upper  portion  of  the  medulla 
oblongata,  just  before  it  joins  the  pons,  it  would  be  shown,  as  in 
the  accompanying  diagram  (Fig.  37),  that  the  horizontal  canal 
fibres  are  externally  placed,  and  that  the  vertical  canals  fibres  are 
mesially  located,  yet  external  to  the  posterior  longitudinal  bundle. 
Now  if  a  section  is  made  higher  up,  in  the  pons  itself,  it  will  be 
noted,  as  shown  in  the  accompanying  diagi'am  (Fig.  37),  that  the 
vertical  canals  fibres  alone  are  represented  and  that  there  are  no 
horizontal  canal  fibres. 

It  will  be  noted  that  these  vestibular  tracts  are  carried  on  the 
one  hand  only  to  the  posterior  longitudinal  bundle,  and  on  the 


TRACT  OF  THE  AUDITORY  APPARATUS  133 


Fig.  35. — Consecutive  series  of  diagrams;  pathways  of  fibres  from  the  right  vertical  canaLs. 


134 


EQUILIBRIUM  AND  VERTIGO 


MeOULLR 
OBLONGATA 


CEReBeUkRl 
NUCLEI       O 

MIDDLE 

CEREBELLAR 

PEDUNCLE 


MEDULLfK 
\OBLQNCATfK 


Fia.  36. — Continuation  of  consecutive  series  of  diagrams;  pathways  of  fibres  from  the  right  vertical  eanali 


TRACT  OF  THE  AUDITORY  APPARATUS 


135 


other  hand  only  to  the  cerebellar  nuclei.  Under  subsequent  chap- 
ters the  paths  will  be  carried  further.  Under  the  chapter  on  nys- 
tagmus  the  tracts  will  be   continued  from  the   posterior  longi- 


FiG.   37. — Diagram   of  cross-section  at  different  levels  of  the  brain-stem.       'H"; 
fibres.     "  V  "==  Vertical  canals  fibres.     In  the  pons  there  are  no  horizontal  canal  fibres. 


^Horizontal  canal 


tudinal  bundle  to  the  eye-muscles.  In  a  similar  way,  under  the 
chapter  on  vertigo,  the  tracts  will  be  continued  from  the  cere- 
bellar nuclei  through  to  the  cerebral  cortex. 


CHAPTER  XV 
VESTIBULAR  NYSTAGMUS 

By  the  term  of  iiystagiiiiis  in  general  is  meant  a  twitching  or 
to-and-fro  movement  of  the  eyes  (Fig.  38).  We  will  consider  only 
that  type  of  nystagmus  which  is  produced  by  stimulation  of  the 
ear  through  the  vestibulo-ocular  tracts,  and  which  is  generally 
spoken  of  as  vestibular  nystagmus.  Vestibular  nystagmus  is  essen- 
tially a  rhythmic  movement  of  the  eyes,  in  that  it  consists  of  a  slow 
movement  of  the  eyes  in  one  direction,  followed  by  a  quick  return 
movement  in  the  opposite  direction.  The  slow  movement  is  gener- 
ally spoken  of  as  the  slow  component  of  nystagmus ;  it  is  the  move- 
ment produced  by  the  ear  stimulation.  The  recovery,  or  quick 
movement  in  the  opposite  direction,  is  entirely  cerebral  in  origin. 
It  is  this  quick  return  movement  of  the  eyes,  however,  that  is  the 
most  consi^icuous,  and  therefore  the  nystagmus  is  named,  perhaps 
unfortunately,  after  this  quick  movement.  We  say  that  the  nys- 
tagmus is  to  the  left  when  the  quick  movement  of  the  eyes  is  to  the 
left.  For  example,  if  by  ear  stimulation  the  eyes  are  made  to  move 
toward  the  right,  the  quick  return  movement  is  to  the  left,  and 
the  nystagmus  is  spoken  of  as  to  the  left.  But  it  must  be  borne 
in  mind  that  the  real  "ear-pull"  in  this  case  is  to  the  right.  In 
other  words,  the  eye  muscles  receive  impulses  from  two  sources, 
from  the  ear  for  the  slow  component  and  from  the  cerebrum  for  the 
quick  component.  We  will  consider  first  the  paths  along  which  the 
impulses  travel  from  the  ear  to  the  eye  muscles.  These  tracts  are 
(1)  Horizontal  semicircular  canal  tracts,  (a)  stimulus  away  from 
the  ampulla,  ih)  stimulus  toward  the  ampulla.  (2)  Vertical  semi- 
circular canals  tracts,  (a)  stimulus  away  from  the  ampullae,  (&') 
stimulus  toward  the  ampullae. 

These  tracts,  the  horizontal  canal  tracts  and  the  vertical  canals 
tracts,  produce  the  true  vestibular  slow  movement  of  the  eyes — 
the  ear-pull. 

In  the  preceding  chapter  it  will  be  remembered  that  we  have 

136 


VESTIBULAR  NYSTAGMUS 


137 


Fig.  38. — Horizontal  nystagmus. 


138  EQUILIBRIUM  AND  VERTIGO 

shown  the  paths  from  the  ear  up  to  the  posterior  longitudinal  bun- 
dle. It  is  this  bundle  which  connects  the  paths  from  the  ear  with 
the  nuclei  controlling  the  eye-movement.  In  addition  the  pos- 
terior longitudinal  bundle  makes  possible  the  associated  movement 
of  the  eyes. 

(1)  Horizontal  canal  tracts  (Figs.  39  and  40).  From  the  hori- 
zontal canal  there  are  two  separate  tracts,  one  conveying  the 
impulse  when  the  current  is  away  from  the  ampulla,  and  the  other 
when  the  current  is  toward  the  ampulla.  Both  these  tracts  connect 
the  horizontal  canal  with  the  III  and  VI  ocular  nuclei,  and  with 
these  nuclei  only  and  in  fact  only  with  that  part  of  the  III  nucleus 
that  controls  the  internal  rectus  muscle. 

(a)  Current  away  from  the  ampulla  in  the  right  horizontal 
canal.  From  the  hair-cells  influenced  by  this  current,  the  fibres 
go  in  the  VIII  Nerve,  through  the  medulla  oblongata  and  Deiters' 
nucleus,  and  thence  to  the  posterior  longitudinal  bundle.  In  the 
bundle  these  fibres  continue  to  the  VI  nucleus  of  the  right  side 
and  the  III  nucleus  of  the  left  side.  The  VI  nucleus  through  the 
VI  Nerve  causes  a  contraction  of  the  external  rectus  muscle  of  the 
right  eye.  The  III  nucleus  through  the  III  Nerve  produces  con- 
traction of  the  internal  rectus  muscle  of  the  left  eye.  The  resultant 
action  is  the  drawing  of  both  eyes  to  the  right. 

Fig.  39  shows  the  current  away  from  the  ampulla  in  the  hori- 
zontal canal;  a  single  hair  is  put  upon  the  stretcli  and  the  fibre 
from  this  hair  proceeds  through  the  VIII  Nerve  to  Deiters '  nucleus, 
and  to  the  posterior  longitudinal  bundle  through  which  it  is  dis- 
tributed to  the  VI  nucleus  and  nerve  of  the  right  side  and  to  the 
III  nucleus  and  nerve  of  the  left  side  causing  both  eyes  to  be  drawn 
to  the  right.  The  diagram  is  constructed  in  an  attempt  to  show 
the  actual  relation  in  the  head.  A  cross-section  of  the  skull  is 
being  viewed  from  above.  It  will  be  noted  that  the  eyes  are 
drawn  in  the  direction  of  the  endolymph  movement  as  expressed 
by  the  arrow  in  the  semicircular  canal. 

(b)  Current  toward  the  ampulla  in  the  right  horizontal  canal. 
From  the  hair-cells  influenced  by  this  movement  the  fibres  continue 
in  the  VIII  Nerve,  through  the  medulla  oblongata  and  Deiters* 
nucleus  and  thence  to  the  posterior  longitudinal  bundle.     In  the 


VESTIBULAR  NYSTAGMUS 


139 


Fig.   39. — Vestibulo-ocular  tract   (producing  nystagmus)    of   horizontal   canal   fibres    (current  away  from 
ampulla).     Eyes  drawn  in  direction  of  endolymph  movement.     Horizontal  section  of  head. 


140  EQUILIBRIUM  AND  VERTIGO 

bundle  these  fibres  continue  to  the  III  nucleus  of  the  right  side  and 
to  the  VI  nucleus  of  the  left.  The  III  nucleus  of  the  right  side 
through  the  III  Nerve  causes  contraction  of  the  internal  rectus 
of  the  right  eye.  The  VI  nucleus  through  the  VI  Nerve  causes 
contraction  of  the  external  rectus  of  the  left  eye.  The  resultant 
action  is  the  drawing  of  both  eyes  to  the  left. 

Fig.  40  shows  the  current  tow^ard  the  ampulla  in  the  right  hori- 
zontal canal ;  the  two  hairs  are  put  upon  the  stretch  and  the  fibres 
from  these  two  hairs  continue  through  Deiters'  nucleus  and  the 
posterior  longitudinal  bundle  to  the  right  III  nucleus  and  nerve 
and  to  the  left  VI  nucleus  and  nerve,  causing  the  eyes  to  be  drawn 
to  the  left.  It  will  be  noted  that  the  eyes  are  drawn  in  the  direction 
of  the-  endolymph  movement  as  shown  by  the  arrow  in  the  semi- 
circular canal. 

It  will  be  observed  in  passing  that  in  both  these  reactions  we 
have  produced  only  a  conjugate  deviation  of  the  eyes,  in  the  one 
case  to  the  right  and  in  the  other  case  to  the  left.  This  is  not  nys- 
tagmus. This  is  only  the  slow  movement  of  nystagmus ;  the  quick 
return  movement  of  the  eyes  in  the  opposite  direction  which  would 
complete  the  nystagmus  will  be  considered  later. 

{a)  Current  away  from  the  ampullae  of  the  superior  canal  and 
of  the  posterior  canal  of  the  right  ear.  From  the  hair-cells  in- 
fluenced by  this  movement  the  fibres  go  through  the  VIII  Nerve, 
ascend  in  the  pons  and  are  distributed  by  the  posterior  longitudinal 
bundles  to  the  IV  nucleus  of  the  right  side  and  the  III  nucleus  of 
the  left  side.  The  IV  nucleus  of  the  right  side  through  the  IV  Nerve 
produces  contraction  of  the  superior  oblique  muscle  of  the  right 
eye,  causing  the  right  eye  to  rotate  to  the  left.  The  III  nucleus  of 
the  left  side  through  the  III  Nerve  produces  contraction  of  the 
inferior  oblique  muscle  of  the  left  eye,  causing  the  left  eye  to  rotate 
to  the  left.  The  resultant  action,  therefore,  is  a  rotary  movement 
of  both  eyes  to  the  left. 

Fig.  41  shows  the  current  away  from  the  ampullae  of  both  the 
superior  canal  and  the  posterior  canal.  This  current  puts  on  the 
stretch  the  two  hairs  in  the  superior  canal  and  in  the  posterior 
canal.  The  fibres  from  these  four  hairs  pass  through  the  VIII 
Nerve  and  in  the  upper  half  of  the  pons  enter  the  posterior  longi- 


VESTIBULAR  NYSTAGMUS 


141 


RIGHT 


LEFT 


Fig   40  — Vestibulo-ocular   tract    (producing  nystagmus)  of   horizontal   canal  fibres  (current  away  from 
ampulla).    Eyes  drawn  in  direction  of  endolymph  movement. 


142 


EQUILIBRIUM  AND  VERTIGO 


RIGHT 


LEFT 


MEDULLA 
OBLONGATA 


FRONTAL  DIAGRAM 


vcstibulo-ocular  tract  of  vertical  canals  fibres 
(producing  nystagmus)  (current  away  from   ampullae) 

Fig.  41. — Eyes  drawn  in  direction  of  endolymph  movement 


VESTIBULAR  NYSTAGMUS 


143 


RIGHT 


LEFT 


MEDULLA 
OBLONGATA 


FRONTAL       DIAGRAM 

VESTIBULO-OCULAR  TRACT    OF   VERTICAL    CANALS    FIBRES 
(producing   nystagmus)  (current   TOWARD   AMPULLAE) 

Fig.  42. — Eyes  drawn  in  direction  of  endolymph  movement. 


144  EQUILIBRIUM  AND  VERTIGO 

tudinal  bundles  to  be  distributed  to  tlie  1\^  nucleus  of  the  right 
side  and  to  the  III  nucleus  of  the  left,  causing  the  upper  meridian 
of  both  eyes  to  be  drawn  to  the  left. 

{b)  Current  toward  the  ampullae  of  the  vertical  canals  of  the 
right  ear,  produces  a  stimulation  of  the  III  nucleus  of  the  right 
side  and  the  IV  nucleus  of  the  left  side.  The  III  nucleus  of  the 
right  side  through  the  III  Nerve  produces  contraction  of  the 
inferior  oblique  muscle  of  the  right  eye,  causing  the  right  eye  to 
rotate  to  the  right.  The  lY  nucleus  of  the  left  side  through  the  IV 
Nerve  produces  contraction  of  the  superior  oblique  muscle  of  the 
left  eye,  causing  the  left  eye  to  rotate  to  the  right.  The  resultant 
action,  therefore,  is  the  rotary  movement  of  both  eyes  to  the  right. 

The  current  toward  the  ampullae  (Fig.  42)  puts  on  the  stretch 
the  one  hair  in  the  superior  canal  and  the  one  hair  in  the  posterior 
canal.  Fibres  from  these  two  hairs  are  distributed  to  the  III 
nucleus  and  nerve  of  the  right  side  and  to  the  IV  nucleus  and  nerve 
of  the  left,  causing  the  upper  meridian  of  both  eyes  to  be  drawn 
to  the  right. 

It  must  be  mentioned  in  passing  that  the  action  of  the  oblique 
muscles  is  not  a  pure  rotary  movement.  The  superior  oblique  also 
causes  the  cornea  to  turn  outward  and  downward.  The  in- 
ferior oblique  causes  the  cornea  to  turn  outward  and  upward. 
In  the  mechanism  of  a  rotary  movement  of  the  eyeball,  therefore, 
there  is  a  definite  action  also  of  the  superior  rectus  and  of  the 
inferior  rectus.  But  as  the  main  action  is  that  of  the  oblique  it  is 
best  for  purposes  of  simplicity  to  consider  them  only. 

Again  it  will  be  remembered  that  in  both  of  these  reactions 
from  the  vertical  canals,  we  have  produced  only  a  conjurjate  devia- 
tion of  the  eyes — a  rotary  movement  in  the  one  case  to  the  left  and 
in  the  other  case  to  the  right.  This  is  not  nystagmus ;  this  is  only 
the  slow  movement  of  nystagmus.  The  quick  return  movement 
of  the  eves  in  the  opposite  direction  which  would  complete  the 
nystag-mus  Avill  now  be  considered. 

The   Cerebral   Fibres  to   the  Eye-Muscle  Nuclei 

The  tracts  already  described  have  caused  a  slow  conjugate 
deviation  of  the  eyes.     The  horizontal  canal  causes  a  horizontal 


VESTIBULAR  NYSTAGMUS  145 

movement  of  the  eyes  to  one  side.  The  vertical  canals  cause  a 
rotary  movement  of  the  eyes  in  one  direction.  This  is  not  nystag- 
mus. The  cerebrum,  conscious  of  the  contraction  of  certain  eye- 
muscles  and  the  relaxation  of  others,  recogiiizes  that  the  eyes  are 
drawn  away  from  the  normal  position  and  sends  impulses  to  the 
exactly  opposite  set  of  eye-muscle  nuclei,  causing  the  quick  return. 
It  is  this  slow  drawing  of  the  eyes  out  of  the  usual  position  and  the 
quick  return  movement  that  together  constitute  nystagmus. 

Example :  the  current  away  from  the  ampulla  of  the  right  hori- 
zontal canal  has  caused  a  conjugate  deviation  of  the  eyes  to  the 
right,  by  stimulation  of  the  VI  nucleus  of  the  right  side  and  the 
III  nucleus  of  the  left.  The  cerebral  fibres  then  cause  a  stimulation 
of  the  III  nucleus  of  the  right  side  and  of  the  VI  nucleus  of  the  left, 
causing  the  eyes  to  be  jerked  quickly  to  the  left.  This  constitutes 
nystagmus  to  the  left. 

If  an  individual  is  under  the  influence  of  ether  and  his  ears 
are  douched,  there  is  produced  a  conjugate  deviation  only.  The 
cerebral  impulses  are  wanting  and  there  is  no  return  movement. 

The  cerebrum  is  not  conscious  of  the  altered  position  of  the 
eyes  by  the  sense  of  sight ;  blind  people,  on  ear  examination,  have 
an  unusually  large  nystagmus.  We  do  know  that  when  the  eyes 
are  drawn  out  of  the  usual  position,  some  eye  muscles  are  con- 
tracted and  others  are  relaxed;  therefore,  the  best  explanation  is 
that  stimuli  from  these  muscles  to  the  cerebral  cortex  notify  the 
higher  centres  of  the  altered  position  of  the  eyes. 

The  cerebral  centre  for  the  quick  component  of  nystagmus  has 
not  been  definitely  located.  The  two  paths  travel  down  through 
the  internal  capsules  into  the  uppermost  portion  of  the  posterior 
longitudinal  bundles  at  the  point  where  the  crura  cerebri  unite  to 
form  the  pons.  The  fibres  are  then  distributed  by  means  of  the 
posterior  longitudinal  bundles  to  the  various  eye-muscle  nuclei. 
The  quick  component  to  the  left  of  both  eyes  is  probably  controlled 
by  a  centre  in  the  right  cerebral  hemisphere,  and  the  left  cerebral 
hemisphere  probably  controls  the  quick  component  of  both  eyes 
to  the  right.  This  is  strongly  suggested  by  data  in  case,  with 
necropsy,  given  in  detail  on  page  382,  case  21. 

10 


146 


EQUILIBRIUM  AND  VERTIGO 


neouLLA 

OBLONGATA 


Fig.  43. — Cerebral  fibres  to  eye-muscle  nuclei  (the  quick  component  of  nystagmus). 


VESTIBULAR  NYSTAGMUS  147 

Planes  of  Nystagmus 

There  are  three  main  planes  of  vestibular  nystagmus — horizon- 
tal, frontal  and  sagittal.  Nystagmus  in  a  horizontal  plane  consists 
of  a  movement  of  the  eyes  toward  the  right  or  toward  the  left. 
Nystagmus  in  the  frontal  j^lane  consists  of  a  rotary  movement  of 
the  eyes  on  their  anteroposterior  axes,  either  toward  the  right  or 
toward  the  left.  Nystagums  in  the  sagittal  plane  consists  of  a 
vertical  movement  of  the  eyes  either  upward  or  downward.  There 
is  an  exact  and  constant  relation  between  the  planes  of  the  semi- 
circular canals  and  the  planes  of  the  nystagmus  produced  by  ear 
stimulation.  The  horizontal  canal,  as  its  name  implies,  is  approxi- 
mately in  a  horizontal  plane.  Stimulation,  therefore,  of  only  the 
horizontal  canal  produces  a  pure  horizontal  nystagmus.  The  fibres 
from  the  horizontal  canal  are  distributed  exclusively  to  the  external 
and  internal  recti  muscles.  This  relation  is  definitely  established 
and  is  very  suggestive  of  itself  that  there  must  be  different  and 
entirely  separate  tracts  from  the  different  canals.  The  best  ex- 
planation is  that  the  horizontal  canal,  for  example,  has  its  own 
fibres  which  are  insulated  from  all  the  other  fibres  throughout  its 
entire  course,  until  the  stimulus  reaches  those  particular  eye  mus- 
cles with  wliich  this  semicircular  canal  is  connected,  namely  the 
external  and  internal  recti. 

The  production  of  a  horizontal  nystagmus  by  stimulation  of 
the  horizontal  canal  is  relatively  simple  to  understand.  The  great 
difficulty  has  been  in  establishing  the  relation  of  the  vertical  canals 
to  the  plane  of  the  nystagmus  which  they  produce.  Perhaps  the 
simplest  explanation  is  as  follows:  The  superior  canal  lies  in  a 
plane  halfway  between  the  frontal  and  the  sagittal,  and  viewed 
from  the  outside  of  the  head,  it  runs  from  a  forward  position, 
backward.  The  posterior  canal  likewise  lies  in  a  plane  halfway 
between  the  frontal  and  the  sagittal,  only  it  runs  forward.  The 
superior  canal,  for  instance,  is  not  placed  in  the  frontal  plane, 
nor  is  the  posterior  canal  placed  in  the  sagittal  plane ;  the  essential 
feature  is  that  these  two  vertical  canals  act  together.  We  know 
this  for  the  following  reasons:  (1)  They  are  both  in  the  vertical 
axis  so  that  any  movement  in  a  vertical  axis  influences  both.  Ex- 
perimentally, either  douching  with  the  head  upright  or  turning 


148  EQUILIBRIUM  AND  NKRTIGO 

with  the  head  forward  or  ha<'k\var<l.  aflccts  hotli  of  these  canals. 
(2)  Aiiatoiiiically  at  thcit-  innermost  point,  they  unite  in  a  common 
cms.  The  movement,  tlierefore,  of  the  endolym})!!  in  one  eanal 
cannot  take  place  without  a  corresponding  movement  of  the  endo- 
lym])h  in  the  other. 

The  plane  of  the  resulting  nystagmus  then  is  the  resultant  of 
the  planes  of  the  vertical  canals.  This  was  first  brought  out  by 
E.  K.  Lewis.  With  the  head  120''  forward,  on  tui-ning,  the  plane 
of  the  movement  of  the  head  is  frontal. 

This  fi-ontal  plane  exactly  bisects  the  phmcs  of  the  two  vcilical 
canals.  It  will  he  noted  that  in  this  ))o>itioii  the  sii])ei-ior  canal 
has  an  arc  of  Ah  inferior  to  this  frontal  plane;  and  that  the  pos- 
terior canal  has  an  arc  of  45  superior  to  the  frontal  plane.  It  is 
the  contribution,  therefore,  from  these  two  canals  that  produces 
a  reaction  in  the  frontal  plane.  Clinically  this  is  true — a  rotary 
nystagmus  is  produced  in  the  frontal  plane.  In  a  similar  way,  if 
the  patient  incline  the  head  00  toward  the  shoulder  and  is  turned 
in  that  position,  the  plane  of  the  tui-ning  is  in  the  sagittal  plane  of 
the  head.  Tt  will  he  ol)sei\('(l  that  the  superior  canal  is  external  to 
the  sagittal  plane  by  an  arc  of  45%  and  that  the  posterior  canal  is 
also  external  to  the  sagittal  ))lane  by  an  arc  of  45  .  Tn  other  words, 
these  two  canals  working  together  ])roduce  the  combined  result 
that  one  canal  would  produce  if  placed  in  the  sagittal  plane.  Clini- 
cally this  also  is  true — a  nystagmus  is  ])roduced  in  the  sagittal 
plane,  a  vertical  nystagmus  u])ward  or  dow'nward. 

Tn  brief,  the  horizontal  canal  produces  a  horizontal  nystagmus. 
The  vertical  canals  j)i-oduce  a  vertical  nystagmus  in  the  frontal 
plane  when  the  vertical  canals  are  influenced  in  the  frontal  plane. 
The  vertical  canals  ])roduce  a  vertical  nystagmus  in  the  sagittal 
plane  when  the  vertical  canals  are  influenced  in  the  sagittal  plane. 

Methods  of  Producing  V^estibular  Nystagmus 
In  onler  to  produce  a  nystagmus  in  any  |)lane  it  is  merely 
necessary  to  j>roduce  a  movement  of  the  endolym})h  in  the  corre- 
sponding plane  of  the  lal)>  rinth.  The  two  routine  methods  of  pro- 
ducing movement  of  the  endolyniph  within  the  labyrinth  are  (1) 
turning,  and  (2)  douching. 


VESTIBULAR  NYSTAGMUS  149 

(1)  Turning.  For  this  method,  a  person  is  placed  in  a  smoothly 
revolving  chair  and  turned.  At  the  beginning  of  the  turning  the 
oii(lolyTny)h  within  the  s('nii(^*irc'iihir  cnDal  lags  Ix'hind    (Ki.ii'.  44"). 

Knd(^lyniph 
Canal 


Fiu.  44". 

After  a  few  turns,  however,  usually  ten,  tlie  endolymph  has  caught 
up  with  the  movement  of  the  canal  and  moves  at  the  same  rate  of 
speed  as  the  canal  (Fig.  44''). 

Endolymph 


t 


-Canal 


The  chair  is  then  stopped.    Tlie  momentum  of  the  endolymj)h  causes 
it  to  continue  to  move  in  the  direction  of  turning  (1^'ig.  45). 

Endolymph 

\ 
^ J ( y  an  al 

Vui.  45. 

With  the  head  in  the  upi'ight  position  (or  moi"e  accurately  30^ 
forward,  which  i)uts  the  horizontal  canals  in  exactly  the  horizontal 
I)lane),  the  horizontal  canals  of  hoth  sides  ai'e  stimulated.  In  the 
right  horizontal  canal  the  endolym})h  current  is  away  fi'om  the 
ampulla,  and  in  the  left  horizontal  cfinal  the  endolymph  is  toward 
the  ampulla.  The  current  away  from  the  amjjulla  of  the  right  side 
produces  a  movement  of  the  eyes  toward  the  same  side,  namely,  the 
right.  The  current  toward  the  ampulla  of  the  left  canal  produces 
a  pulling  of  the  eyes  to  the  opposite  side,  namely,  the  right.  In 
other  words,  the  two  canals  supplement  eacli  other  in  that  they  each 
produce  a  pulling  of  the  eyes  to  the  right.  It  has  been  proven 
that  the  stimulus  toward  the  ampulla  of  the  horizontal  canal  is 
twice  as  strong  as  the  stimulus  away  from  the  ampulla.  In  this 
instance,  therefore,  two-thirds  of  the  reaction  is  due  to  the  left 
canal  and  one-third  to  the  right  canal.  (Of  course  the  nystagmus 
in  this  instance  would  be  to  the  left.  We  will  discuss  only  the  ves- 
tibular or  slow  component.) 

During  the  turning  the  canal  is  moving  away  from  the  endo- 
lymph   (Fig.  38).     The  current,  therefore,  in  the  right  canal  is 


150  EQUILIBRIUM  AND^VERTIGO 

toward  the  aiiipiilla ;  in  the  left  canal  it  is  away  from  the  ampulla. 
The  result,  therefore,  during  the  turning  is  a  vestibular  pull  of 
the  eyes  to  the  left,  that  is  to  say,  a  nystagmus  toward  the  right. 
It  was  this  nystagmus  during  turning  that  was  studied  by  the 
original  investigators.  A  revolving  platform  was  constructed  on 
which  the  examiner  was  rotated  with  the  patient,  and  w^ith  his  finger 
placed  over  the  patient's  eyelids  he  could  feel  the  twitching  move- 
ment. The  after-iMYmwg  nystagmus,  however,  is  so  much  more 
easily  observed  that  the  old  method  has  become  obsolete.  It  is  only 
of  academic  interest  to  note  that  during  the  turning  the  canal  moves 
away  from  the  endolymph,  and  that  after  stopping  the  endolymph 
moves  away  from  the  canal.  Also  that  the  nystagmus  after  turn- 
ing, for  this  reason,  is  in  exactly  the  opposite  direction  to  the 
nystagmus  during  the  turning. 

Tabi>e  of  Xystagmus  After  Turning 
For  the  convenience  of  the  reader,  we  now  present  a  tabulated 
list  of  the  various  forms  of  nystagmus  produced  after  turning 
with  the  head  in  various  positions. 

Turning  to  the  riplit  with  the  liead  upright  produces  a  horizontal  nystagmus 
to  the  left.  — >■ 

Turning  to  the  left  with  the  head  upright  produces  a  horizontal  nystagmus 
to  the  right.  ■< 

Turning  to  tiie  right  with  the  head  60""  backward  produces  a  rotarj'  nystagmus 
to  the  left.  /^ 

Turning  to  the  left  with  the  head  60°  backward  produces  a  rotary  nystagmus 
to  the  right.  ^^^ 

Tumino-  to  the  right  with  the  head  90°  forward  produces  a  rotary  nystagmus 
to  the  left.  r~^ 

Turnino'  to  the  left  with  the  head  90°  forward  produces  a  rotary  nystagmus 
to  the  right.  ^(^^ 

Turninc  to  the  right  with  the  head  inclined  toward  the  right  shoulder  produces 
a  vertical  nystagmus  downward.  «f 

Turnin"  to  the  left  with  the  head  inclined  toward  the  right  shoulder  produce-s 
a  vertical  nystagmus  upward.  f 

Turnino'  to  the  riglit  with  the  head  inclined  toward  the  left  shoulder  produces 
a  vertical  nystagmus  upward.  f 

Turning  to  the  left  with  the  head  inclined  towaid  the  left  shoulder  produces 
a  vertical  nj'stagnius  downward.  | 


VESTIBULAR  NYSTAGMUS  151 

(2)  Caloric.  The  caloric  test  of  Barany  consists  in  douching 
a  person's  ear  with  cold  or  hot  water.  Recalling  that  the  essential 
feature  in  the  production  of  nystagmus  is  a  movement  of  the  endo- 
lymph  within  the  labyrinth,  we  accomplish  it  in  this  test  by  either 
cooling  or  warming  one  spot  of  the  labyrinthine  capsule.  The 
endolymph  at  that  point  is  either  cooled  or  warmed  and  in  conse- 
quence either  sinks  or  rises.  Cooling  increases  the  specific  gravity 
of  the  endolymph  and  causes  it  to  sink.  Heating  decreases  the 
specific  gravity  and  causes  the  endolymph  to  rise.  In  both  in- 
stances a  current  is  established,  but  in  the  exactly  opposite  direc- 
tion. This  naturally  takes  place  only  in  an  up-and-down  direction. 
The  temperature  of  the  endolymph  is  approximately  100°.  In 
order  to  produce  this  reaction  the  water  is  used  either  20°  to  40^ 
below  the  body  temperature  if  we  desire  to  cool  the  endolymph,  or 
10°  to  15°  above  the  temperature  of  the  endolymph,  if  we  desire 
to  heat  it. 

With  the  head  in  the  upright  position,  douching,  of  course, 
influences  the  vertical  canals  (see  Fig.  2).  This  consequently  pro- 
duces a  nystagmus  in  the  frontal  plane.  Cold  water  causes  a  flow 
of  the  endolymph  downward  toward  the  ampullae  of  the  vertical 
canals,  producing  a  vestibular  pull  of  the  upper  meridian  of  the 
eyes  toward  the  same  side;  in  other  words,  a  nystagmus  to  the 
opposite  side.  Hot  water  with  the  head  upright,  naturally  pro- 
duces exactly  the  opposite  reaction,  namely,  as  the  flowing  is  away 
from  the  ampullae,  the  vestibular  pull  of  the  eyes  is  to  the  opposite 
side  and  the  nystagmus  to  the  same  side.  With  the  head  inclined 
60°  backward,  the  horizontal  canal  then  assumes  the  vertical  posi- 
tion. Douching  in  this  position  with  cold  water  consequently 
causes  a  flow  of  the  endolymph  away  from  the  ampulla,  producing 
a  vestibular  pull  of  the  eyes  toward  the  same  side  in  the  horizontal 
plane  of  the  head,  that  is  to  say,  a  nystagmus  to  the  opposite  side. 
This  reaction  being  produced  by  the  horizontal  canal  is,  of  course, 
a  horizontal  nystagmus.  Similarly  if  the  head  is  inclined  120° 
forward  and  the  ear  douched  with  cold  water,  the  endolymph  cur- 
rent is  toward  the  ampulla.  This  produces  a  vestibular  drawing 
of  the  eyes  to  the  opposite  side,  that  is  to  say,  a  nystagmus  to  the 


152  EQUILIBRIUM  AND  VERTIGO 

same  side.     As  it  was  the  horizontal  canal  that  was  affected  there 
is  produced  a  nystagmus  in  the  horizontal  plane. 

For  the  convenience  of  the  reader,  the  various  reactions  obtained 
by  douching  are  tabulated  below. 

Nystagmus  After  Douching 

Doucliing  the  right  ear  with  the  head  upright,  water  68°.  produces  a  rotarj' 
instagnius  to  the  left.  ^'"'^ 

Douching  the  left  ear  with  the  head  upright,  water  68°,  produces  a  rotary 
nj'stagTnus  to  the  I'ight.  /"    \ 

Douching  the  right  ear  with  the  head  60°  backward,  water  68°,  produces  a 
horizontal  nystaginus  to  the  left.  — >- 

Douching  the  left  ear  with  the  head  60°  backward,  water  68°,  produces  a 
horizontal  nystagmus  to  the  right.       -< — 

Douching  the  right  ear  with  the  head  120°  forward,  water  68°,  jDroduees  a 
horizontal  nystagmus  to  the  right.        ■< — 

Douching  the  left  ear  with  the  head  120°  forward,  water  68°,  produces  a 
horizontal   nystagiiius    to  the  left.      — >- 

Douching  the  right  ear  with  the  head  upright,  water  112°,  produces  a  rotary 
nystagmus  to  the  right.  ^^~^ 

Douching  the  left  ear  with  the  head  upright,  water  112°,  produces  a  rotary 
nystagmus  to  the  left.  ^    \ 

Doucliing  the  right  ear  with  the  head  60°  backward,  water  112°,  produces  a 
horizontal  nystagmus  to  the  right.  ■< — 

Douching  the  left  ear  with  the  head  60°  backward,  water  112°,  produces  a 
horizontal  nystagmus  to  the  left.  — >■ 

Douching  the  right  ear  with  the  head  120°  fonvard,  water  112°,  produces  a 
horizontal  nystagmus  to  the  left.  — -> 

Douching  the  left  ear  with  the  head  120°  forward,  water  112°,  jDroduces  a 
horizontal  nystagmus  to  the  right.  ■< — 

It  must  not  be  considered  that  all  these  tables  of  reactions  must 
be  remembered.  After  one  has  become  familiar  with  the  vestibular 
tests  he  comes  to  know  what  reactions  to  expect  in  the  normal,  just 
as  he  is  familiar  with  the  use  of  the  tuning-fork  or  any  other  routine 
procedure.  Further,  it  is  not  necessary  to  remember  a  single 
reaction.  All  that  we  need  to  remember  is  tJie  eyes  are  always 
drawn  in  the  direction  of  the  endolymph  movement.  It  is  an  unfail- 
ing rule  and  makes  this  apparently  complex  subject  extremely 
simple. 


CHAPTER    XVI 
VESTIBULAR  VERTIGO 

A^ERTiGo  from  whatever  cause  is  a  subjective  sensation  of  a 
disturbed  relationship  to  objects  in  space.  This  disturbance  is 
necessarily  due  to  an  alteration,  either  stimulating  or  depressing, 
of  some  portion  of  the  vestibular  apparatus.  Inasmuch  as  the  tests 
of  the  kinetic-static  labyrinth  disturb  the  vestibular  apparatus, 
vertigo  is  necessarily  a  resulting  phenomenon.  It  is  distinctly  a 
cerebral  disturbance  resulting  from  impulses  carried  from  the  ear 
to  the  cerebral  cortex. 

In  Chapter  XIV  the  tracts  producing  vertigo  are  described  as 
extending  from  the  ear,  through  the  VIII  Nerve,  through  the  brain- 
stem, and  through  the  cerebellar  peduncles  as  far  as  the  cerebellar 
nuclei  ( Figs.  32,  33,  34,  35  and  36).  There  are  two  separate  aiferent 
paths  from  the  ear  to  the  cerebral  cortex,  resulting  in  vertigo  from 
ear-stimulation:  (1)  The  horizontal  canal  tracts,  and  (2)  the  ver- 
tical canals  tracts. 

Fig.  46  shows  the  current  away  from  the  ampulla  in  the  right 
horizontal  canal.  A  single  hair  is  put  upon  the  stretch ;  the  nerve- 
fibre  from  the  hair  is  represented  as  entering  the  VIII  Nerve,  going 
to  Deiters'  nucleus,  entering  the  cerebellum  through  the  inferior 
peduncle  and  going  to  the  vestibular  cerebellar  nuclei.  From  the 
nuclei  the  heavy  line  represents  the  main  pathway  to  the  cerebral 
cortex,  passing  from  the  cerebellum  through  the  right  superior 
cerebellar  peduncle  in  which  it  decussates  in  the  base  of  the  cere- 
bral crura,  and  continuing  through  the  special  sensory  tract  to  the 
posterior  portion  of  the  temporal  lobe  of  the  left  side.  Another 
pathway  from  the  cerebellar  nuclei  is  represented  by  a  thinner 
line  extending  through  the  right  superior  peduncle,  but  instead 
of  decussating  to  the  opposite  side,  this  minor  path  continues 
through  the  cerebral  crus  of  the  same  side  to  the  temporal  lobe 
of  the   same   side.     Those  pathAvays   from  the  fibres   influenced 

153 


154 


EQUILIBRIUM  AND  VERTIGO 


by  a  current  away  from  the  ampulla  in  the  right  horizontal  canal 
produce  a  subjective  sensation  of  turning  to  the  left.  It  will  be 
noted  that  the  vertigo  is  in  a  direction  opposite  to  the  direction  of 


RIGHT 


LEFT 


MEDULLA 
OBLONGATA 


Fig.  46.— Vpstibulo-cerebello-oerebral  tract  for  horizontal  canal   fibres  (producing  vertigo)  (current  away 

from  ampullae). 

the  endolymph  movement  as  represented  by  the  arrow  in  the  semi- 
circular canal. 

Figure  47  is  the  same  as  the  preceding  diagram,  except  that 


VESTIBULAR  VERTIGO 


155 


the  current  toward  the  ampulla  puts  upon  the  stretch  the  two 
hairs  on  the  other  side  of  the  crista.     Tliis  stimulation  causes  a 


RIGHT 


LEFT 


MEDULLA 
OBLONGATA 


Fig.  47.— Vestibulo-cerebello-cerebral  tract  for  horizontal  canal  fibres  (producing  vertigo). 

subjective  sensation  of  turning  to  the  right— in  a  direction  opposite 
to  the  endolymph  movement. 

Figure  48  shows  the  vertical  canals  with  the  current   away 
from  the  ampulla.    The  two  hairs  in  the  superior  canal  and  the  two 


156 


EQUILIBRIUM  AND  VERTIGO 


hairs  in  the  posterior  canal  are  put  upon  the  stretch.  From  these 
hairs  the  fibres  pass  through  tlie  \^III  Nerve,  ascend  in  the  pons 
to  a  point  above  the  middle  of  the  ]ions,  wliere  they  enter  the 

RIGHT  _  LEFT 


SUPERIOR 
CEREBELLAR     PEDUNCLE 


Superior 

^  Y^'^^^^'-LAR   PEDUNCLE 


MEDULLA 
OBLONGATA 


Fig.  48.— Vestibulo-cerebello-cerebral  tract  for  vertical  canals  fibres  (producine  verlii-o^ 
(current  away  from  ampullse). 

cerebellum  through  the  middle  cerebellar  peduncle  and  go  to  the 
cerebellar  nuclei  of  the  same  side.  From  the  cerebellar  nuclei  the 
course  of  these  fibres  is  the  same  as  that  of  the  horizontal  canal 


VESTIBULAR  VERTIGO 


157 


fibres.  This  stimulation,  of  the  current  away  from  the  ampullae, 
produces  a  subjective  sensation  of  falling  to  the  right— in  a  direc- 
tion opposite  to  the  endolymph  movement. 


SUPERIOR 
CEREBELLAR  PEDUNCLE 


MEDULLA 
OBLONGATA 


Fig.  49. — Vestibulo-cerebello-cerebral  tract  for  vertical  canals  fibres  (producing  vertigo). 

Figure  49  is  identical  with  the  preceding  diagram  except  that 
the  current  in  the  vertical  canals  is  toward  the  ampullae,  putting 
upon  the  stretch  the  single  hair  in  the  superior  canal  and  the  single 


158  EQUnJBRIUM  AND  ^  ERTIGO 

hair  in  the  posterior  canal.  This  stimulation  causes  a  subjective 
sensation  of  falling  to  the  left— in  a  direction  opposite  to  the  endo- 
lympli  movement. 

The  cortical  centre  for  the  reception  of  vestibular  impulses  has 
been  postulated  by  Mills  to  be  in  the  posterior  portion  of  the  first 
and  second  temporal  convolutions,  adjacent  to  the  cortical  area 
for  hearing.  Mills  considers  that  there  is  such  a  centre  in  each 
cerebral  hemisphere  and  agrees  with  Dana  that  this  centre  is  prob- 
ably more  highly  developed  in  the  right  temporal  region.  It  is  not 
to  be  considered  that  the  sensation  of  vertigo  is  appreciated  in 
the  two  cortical  areas  in  the  two  temporal  lobes.  These  vestibular 
centres  constitute  the  termini  of  the  vestibular  fibres;  association 
fibres  in  turn  connect  these  centres  with  other  parts  of  the  cerebral 
cortex,  particularly  the  frontal  lobes. 

The  Planes  of  Vestibular  Vertigo 
The  vestibular  reaction  of  vertigo,  just  like  the  reaction  of 
nystagTnus,  manifests  itself  in  certain  definite  planes:  (1)  Sensa- 
tion of  turning  in  the  horizontal  plane,  either  from  the  right  to 
the  left  or  from  the  left  to  the  right.  (2)  Sensation  of  turning  in 
the  frontal  plane,  consisting  of  a  sensation  of  falling  to  the  rigin 
or  falling  to  the  left.  (3)  Sensation  of  turning  in  the  sagittal 
plane,  consisting  of  a  sensation  of  falling  forward  or  backward. 

The  sensation  of  movement  in  the  horizontal  plane  is  produced 
only  by  the  horizontal  canal  or  canals.  This  is  illustrated  by  turn- 
ing the  patient  with  the  head  30^  forward. 

The  sensation  of  turning  in  the  frontal  plane  is  produced  only 
when  the  vertical  canals  are  influenced  in  the  frontal  plane.  When 
the  patient  is  turned  with  the  head  forward  or  backward,  the  plane 
of  the  rotation  is  frontal.  Xow  if  after  turning  (Fig.  50)  the  head 
is  kept  forward  or  backward,  the  subjective  sensation  is  of  turning 
in  the  frontal  plane,  which  in  this  position  of  the  head  is  parallel 
to  the  floor.  The  sensation  is  therefore  the  same  as  after  turning 
with  the  head  upright,  namely,  a  movement  about  one's  own  axis 
either  to  the  right  or  to  the  left.  As  it  is  a  sensation  of  turning 
in  a  plane  parallel  to  the  floor,  it  is  not  unpleasant.  If,  however, 
after  turning,  the  patient's  head  is  raised  to  the  upright  position. 


VESTIBULAR  VERTIGO  159 

the  frontal  plane  then  becomes  at  right  angles  to  the  floor  and  the 
sensation  is  that  of  falling  in  the  frontal  plane  either  to  the  right 
or  to  the  left,  and  is  therefore  incidentally  unpleasant. 

The  sensation  of  turning  in  the  sagittal  plane  is  produced  only 
when  the  vertical  canals  are  influenced  in  the  sagittal  plane.  When 
the  patient  is  turned  with  the  head  inclined  well  over  toward  the 
shoulder,  the  plane  of  the  rotation  is  sagittal.  Now  if  after  turn- 
ing, the  head  is  kept  in  this  same  position  toward  the  shoulder, 
the  subjective  sensation  is  of  turning  in  the  sagittal  plane,  which 
in  this  position  of  the  head  is  parallel  to  the  floor.  The  sensation 
is  therefore  the  same  as  after  turning  with  the  head  upright, 
namely  a  movement  about  one's  own  axis  either  to  the  right  or  to 
the  left.  As  it  is  a  sensation  of  turning  in  a  plane  parallel  to  the 
floor,  it  is  not  unpleasant.  If,  however,  after  turning,  the  patient's 
head  is  raised  to  the  upright  position,  the  sagittal  plane  then  be- 
comes at  right  angles  to  the  floor  and  the  sensation  is  that  of  falling 
in  the  sagittal  plane ;  this  consists  of  a  feeling  of  pitching  forwards 
or  backward,  and  is  therefore  incidentally  unpleasant. 

In  speaking  of  this  unpleasantness  resulting  from  endolymph 
movement  in  the  vertical  plane,  we  may  recall  the  illustration  of 
seasickness.  Barany  calls  attention  to  the  fact  that  a  ship  at  sea 
tosses  in  various  planes: 

(1)  The  horizontal  plane,  from  right  to  left.  This  movement, 
however,  is  usually  very  slight  and  unfortunately,  as  we  have 
already  shown,  this  is  the  only  plane  of  movement  that  is  not 
unpleasant. 

(2)  The  frontal  plane — namely,  a  rolling  of  the  ship  from  side 
to  side.  If  the  individual  is  standing  facing  the  bow  of  the  ship, 
the  vertical  canals  are  affected  in  the  frontal  plane.  This  is  un- 
pleasant. If,  therefore,  the  individual  lies  down  with  his  head 
or  his  feet  toward  the  bow,  the  rolling  movement  then  affects  his 
horizontal  canals,  and  the  unpleasantness  disappears. 

(3)  The  sagittal  plane — namely,  a  pitching  of  the  ship  fore  and 
aft.  If  the  individual  is  standing  facing  the  bow  of  the  ship,  the 
vertical  canals  are  affected  in  the  sagittal  plane.  This  is  un- 
pleasant.    If,  therefore,  the  person  lies  down  with  the  line  of  the 


f 


ji"    i. 


Fig.  50.— Turning  to  the  left  with  the  head  60°  back. 


VESTIBULAR  VERTIGO  161 

body  extending  across  the  ship  from  starboard  to  port,  the  pitch- 
ing movement  then  aflFects  the  horizontal  canals,  and  the  unpleas- 
antness disappears. 

The  up-and-down  movement  of  the  ship,  rising  and  sinking,  in 
a  similar  way  affects  the  vertical  canals  when  the  individual  is  in 
the  upright  position.  The  unpleasantness  caused  by  this  move- 
ment is  also  relieved  when  the  individual  lies  down,  as  then  the 
up-and-down  movement  affects  the  horizontal  canals,  the  stimu- 
lation of  which  is  so  much  less  unpleasant. 

The  Artificial  Psoduction  of  Vestibular  Vertigo 

The  subjective  sensation  of  vertigo  after  ear  stimulation  is  due 
to  the  movement  in  one  direction  or  the  other  of  the  hair-cells  of  the 
end-organ  in  the  labyrinth ;  such  sensations  can  be  produced  either 
by  turning  an  individual  in  a  revolving  chair  or  by  douching  the 
ears. 

Vertigo  After  Turning 

If  a  person  is  turned  with  the  head  upright  toward  the  right, 
with  eyes  closed,  his  first  sensation  is  of  turning  toward  the  right. 
This  is  due  to  the  lagging  behind  of  the  endolymph  in  the  hori- 
zontal semicircular  canals.  Diagramatically  this  can  be  repre- 
sented as  in  preceding  chapter,  in  explaining  nystagmus : 

Endolymph  lags  behind 
^ i_ ^Canal 


Now  as  the  turning  is  continued  the  endolymph  catches  up  to 
the  movement  of  the  body  and  the  individual  no  longer  jeels  that 
he  is  turning,  although  actually  he  is  turning. 

Endolymph 


On  stopping  the  chair,  the  endolymph  continues  to  move  and 
the  person  has  a  sensation  of  turning  in  the  opposite  direction, 
11 


162  p:quilibrium  and  vertigo 

namely  to  the  left,  although  he  is  actually  sitting  absolutely  quiet 
in  the  chair. 


Endolvmph . 


-Canal 


The  essential  feature  of  the  subjective  sensation  of  vertigo 
after  turning  is  that  after  turning  to  the  right  the  individual  feels 
he  is  turning  to  the  left,  regardless  of  the  position  of  the  head. 
After  turning  to  the  right  with  the  head  forward,  or  after  turning 
to  the  right  with  the  head  backward,  although  the  movement  of  the 
endol^ymph  is  in  a  diametrically  opposite  direction,  the  result  is 
the  same,  namely,  a  subjective  sensation  of  turning  to  the  left.  It 
will  be  recalled  that  this  is  not  true  of  nystagmus.  Turning  to  the 
right  with  the  head  forward  produces  nystagmus  to  the  left;  turn- 
ing to  the  right  w^ith  the  head  backw^ard  produces  nystagmus  to  the 
right.  This  is  because  nystagmus  is  a  simple  reflex  depending 
directly  on  the  direction  of  the  endolyraph  movement.  Vertigo,  on 
the  other  hand,  is  a  cerebral  phenomenon ;  in  determining  the 
interpretation  of  the  sensation  of  movement,  the  cerebrum  takes 
into  consideration  the  position  of  the  head  and  in  this  way  properly 
interprets  the  significance  of  the  endolymph  movement  with  the 
head  in  any  given  position. 

The  following  is  a  table  of  the  subjective  sensations  of  vertigo 
produced  by  turning: 

Turning'  to  the  right  with  the  head  upright  produces  a  sensation  of  movement 
to  the  left  in  the  horizontal  plane. 

Turning  to  the  left  with  the  head  in  the  upright  position  produces  a  sensation 
of  turning  to  the  right  in  the  horizontal  plane. 

Turning  to  the  right  with  the  head  forward  120°  produces:  (a)  With  the  head 
kept  in  the  forward  position,  a  sensation  of  turning  to  the  left  in  the  horizontal 
plane.  (6)  With  the  head  brought  upright,  a  sensation  of  falling  to  the  left  in 
the  frontal  plane. 

Turning  to  the  left  with  the  head  forward  120°  produces:  (a)  With  the  head 
kept  in  the  forward  position,  a  sensation  of  turning  to  the  right  in  the  horizontal 
plane,  (b)  Bringing  the  head  to  the  upright  position,  a  sensation  of  falling  to 
the  right  in  the  frontal  plane. 

Turning  to  the  right  with  the  head  back  60°  produces:  (a)  With  the  head 
kept  in  this  backward  position,  a  sensation  of  turning  to  the  left  in  the  horizontal 


VESTIBULAR  VERTIGO  168 

plane,     (b)  With  tlie  head  brought  uiiright,  a  sensation  of  falling-  to  the  right  in 
the  frontal  plane. 

Tunung-  to  tlie  left,  head  back  60°,  produces:  (a)  With  the  head  kept  in  this 
backward  i^osition,  a  sensation  of  turning  to  the  right  in  the  horizontal  plane,  ib) 
Head  brought  to  upright  position,  a  sensation  of  falling  to  the  left  in  the  frontal 
plane. 

It  is  not  necessary  to  memorize  all  the  subjective  sensations  of 
turning.  In  tlie  chapter  on  nystagmus  it  is  noted  that  the  eyes  are 
always  drawn  in  the  direction  of  the  endolymph  movement.  As 
regards  the  subjective  sensation  of  systematized  vertigo,  the  fol- 
lowing rule  should  be  remembered :  Vertigo  is  always  in  the  direc- 
tion opposite  to  the  endolymph  movement. 

Experience,  through  sight  and  muscle-sense,  has  taught  the 
individual  that  when  he  turns  to  the  right  and  the  endolymph  is 
lagging  behind,  that  he  is  turning  to  the  right.  When  he  stops 
and  the  endolymph  continues  to  go  to  the  right,  he  therefore  has  a 
subjective  sensation  of  turning  to  the  left.  The  original  basis  for 
his  mental  interpretation  of  the  endolymph  is  that  when  he  turns 
to  the  right  the  endolymph  moves  relatively  to  the  left.  The 
mental  interpretation,  therefore,  is  always  of  a  subjective  sensa- 
tion of  movement  in  a  direction  opposite  to  the  endolymph  current. 

Vertigo  After  Douching 
I. 

On  douching  the  ear  with  either  cold  or  hot  water,  continued  a 

sufficient  time  to  permit  a  chilling  or  warming  of  the  outer  wall  of 

the  labyrinth,  there  occurs  a  systematized  vestibular  vertigo.    The 

following  is  a  table  of  the  subjective  sensations  of  vertigo  produced 

by  the  caloric  test: 


Douching  the  right  ear,  head  upright,  water  6S°,  produces  sensation  of  falling 
to  the  left  in  the  frontal  plane. 

Douching  the  left  ear  with  the  head  upright,  water  6S°,  produces  sensation  of 
falling  to  the  right  in  the  frontal  plane. 

Douching  the  right  ear  with  the  head  120°  fonvard,  water  68°,  produces 
sensation  of  falling  to  the  right. 

Douching  the  left  ear  with  the  head  120°  forward,  water  68°,  produces  sensation 
of  falling  to  the  left. 


164  EQUILIBRIUM  AND  VERTIGO 

Douching  the  right  ear.  liead  back  60°,  water  68°,  produces  sensation  of  falling 
to   the  left. 

Douching  the  left  ear.  head  back  60°,  water  68°,  produces  sensation  of  falling 
to  the  right. 

Douching  the  right  ear,  head  upright,  water  112°,  produces  .sensation  of  falling 
to  the  right  in  the  frontal  plane. 

Douching  the  left  ear,  head  upright,  water  112°,  produces  sensation  of  falling 
to  the  left  in  the  frontal  plane. 

Douching  the  right  ear,  head  120°  foi-ward,  water  112°,  produces  sensation  of 
falling  to  the  left. 

Douching  the  left  ear,  head  120°  fonvard,  water  112°,  produces  sensation  of 
falling  to  the  right. 

Douching  the  right  ear,  head  back  60°,  water  112°,  produces  sensation  of  falling 
to  the  right. 

Douching  the  left  ear,  head  back  60°,  water  112°,  produces  sensation  of  falling 
to  the  left. 


CHAPTER    XVII 

POINTING  TESTS  OF  BARANY 

In  discussing  the  pointing  tests  it  is  first  necessary  to  consider 
the  functions  of  orientation  and  equilibration.  While  these  two 
functions  are  co-related  they  are  nevertheless  not  identical.  By 
orientation  is  meant  the  determining  of  the  relation  of  the  body 
to  space.  By  equilibration  is  meant  the  maintenance  of  position, 
whether  walking,  standing  or  sitting.  "Pointing"  is  a  cerebral 
act  of  orientation. 

In  1909  Barany,  while  working  on  the  physiology  of  the  ear- 
tests,  became  interested  in  the  pointing  tests  of  von  Graefe.  These 
are  tests  for  eye-muscle  palsy.  The  patient  is  allowed  to  look  at  a 
fixed  object  with  the  suspected  eye,  keeping  the  normal  eye  closed. 
In  other  words,  by  means  of  the  sight  of  the  suspected  eye,  he  fixes 
in  his  mind  the  supposed  position  of  the  external  object.  Then 
with  both  eyes  shut,  he  attempts  to  point  to  the  object  with  his 
finger.  If  he  is  able  to  touch  it,  it  shows  that  there  is  no  eye-muscle 
palsy.  If  he  p«5^-points,  how^ever,  it  shows  that  there  is  a  palsy. 
This  is  because  the  eye,  being  out  of  the  normal  line,  has  given  him 
false  information  as  to  the  position  of  the  external  object.  It  then 
occurred  to  Barany  that  if  the  misplaced  position  of  the  eye-ball, 
due  to  palsy,  would  cause  a  past-pointing,  the  misplaced  position 
of  the  eye  during  a  nystagmus  would  also  probably  produce  a  past- 
pointing.  This  he  found  to  be  true.  After  the  turning  or  douch- 
ing, instead  of  being  able  to  touch  the  external  object,  the  indi- 
vidual pointed  ])ast  the  object,  to  one  side  or  the  other.  On  further 
examination,  however,  Barany  found  that  with  the  eyes  closed  the 
past-pointing  was  present  just  the  same  as  when  the  eyes  were 
open ;  in  other  words,  it  was  not  an  ocular  phenomenon  at  all. 
Past-pointing  after  turning  or  douching  is  not  due  to  the  misplaced 
position  of  the  eyes  or  to  the  disturbance  of  vision,  but  is  due  to 
the  stimulation  of  the  ears. 

165 


IGG  EQUILIBRIUM  AND  VERTIGO 

It  is  this  contribution  of  Barany  that  was  epoch-making  in  the 
study  of  the  relation  of  the  ears  to  the  central  nervous  system.  It 
is  by  means  of  these  pointing-tests  that  we  come  to  realize  the 
intimate  relation  between  the  ears  and  every  portion  of  the  body- 
musculature  through  the  nervous  system. 

Now  as  regards  the  pointing-tests  themselves;  the  normal  per- 
son is  always  aware  of  the  location  of  his  hand  or  finger  in  space. 
Furthermore,  with  his  eyes  closed  he  is  aware  of  the  exact  position 
in  space  of  objects  previously  located.  Therefore,  having  first 
touched  with  his  finger  an  object  in  space,  he  is  able  with  the  eyes 
closed  to  move  his  finger  away  from  the  object  and  then  come  back 
and  find  it  again ;  and  this,  not  as  a  mere  approximation  comjjleted 
by  groping  for  the  object,  but  as  a  prompt,  assured  and  exact 
return  to  the  point  previously  touched. 

SPOiSTTAXEOUS  PoiNTIXG  TeSTS 

The  spontaneous  tests  consist  of  determining  the  patient's 
ability,  with  the  eyes  shut,  to  find  the  finger  of  the  examiner  which 
he  has  previously  felt.  All  normal  individuals  are  always  able  to 
find  the  finger  almost  or  quite  as  readily  as  if  the  eyes  were  open. 

Shoulder  from  above  (Fig.  51)  shows  the  upper  extremity  of  tlie 
patient  extended  straight  in  front  of  him.  His  fist  is  closed  with 
the  exception  of  the  forefinger,  which  is  extended  straight  in  front 
of  liim.  He  is  blindfolded;  this  is  not  necessary,  provided  we  are 
sure  that  the  patient  can  be  trusted  to  keep  his  eyes  closed.  The 
examiner  places  the  finger  of  the  patient  directly  above  his  own 
forefinger.  The  patient  is  told  to  fix  in  his  mind  the  exact  position 
of  the  examiner's  finger.  The  examiner  then  says  ''Up."  The 
patient  raises  his  arm  to  the  vertical  position  and  then  immediately 
brings  it  back  again  to  find  the  examiner's  finger.  Fig.  52  shows 
the  same  test,  but  the  moving  pictures  were  taken  from  above  and 
behind  the  patient,  in  order  to  show  more  clearly  that  there  is  no 
lateral  deviation  of  his  finger. 

Shoulder  from  below  (Fio:.  53).  The  patient's  forefinger  is 
placed  immediately  underneath  the  forefinger  of  the  examiner,  and 


■'*'^*^mmr0- 


Fio.  51. — Sl.oulc'er  from  above. 


r 


'i^ 


ay 


Fig.  52. — Shoulder  from  above.      Patient  raises  finger  to  vertical  position  and    then  lowers  it  and  again 

touches  finger  of  examiner. 


^       ^ 


i-^ 


Fig.  53. — Shoulder  from  below. 


170  EQUILIBRITM  AND  VERTIGO 

the  examiiior  says  "Down."  The  patient  slowly  lowers  liis  arm 
and  immediately  brings  it  back  again  to  touch  the  finger  of  the 
examiner. 

Shoulder  from  the  side  (Fig.  54).  The  patient's  finger  is  ])la('ed 
alongside  of  the  finger  of  the  examiner.  The  examiner  says  ' '  Out, ' ' 
the  patient  brings  his  arm  out  sideways  and  immediately  brings  it 
baek  to  find  the  finger  of  the  examiner. 

Shoulder  to  the  side  (Fig.  55).  The  patient  touches  the  exam- 
iner's finger  in  the  side  position,  brings  his  arm  horizontally  for- 
ward to  the  middle  line  and  immediately  brings  it  back  and  finds  the 
finger  of  the  examiner. 

Elbow  from  below  (Fig.  56).  Oidy  the  forearm  must  be  used  in 
this  movement.  The  arm  is  therefore  held  firmly  by  an  assistant, 
as  shown  in  tlie  moving  })ietures.  The  examiner  places  his  own 
right  forefinger  at  a  point  near  the  patient's  head,  and  as  this  posi- 
tion is  somewhat  awkward  for  the  examiner  it  is  best  for  him  to 
support  his  right  hand  with  his  left  hand,  as  shown  in  the  pictures. 
The  patient's  finger  is  placed  just  in  front  of  the  examiner's  finger 
and  the  examiner  says  "Down."  The  patient  lowers  the  forearm 
to  the  horizontal  position  and  then  brings  it  back  and  finds  the  finger 
of  the  examiner. 

Elbow  from  above  (Fig.  57).  The  patient's  arm  is  held  by  an 
assistant;  the  examiner  places  his  forefinger  beneath  the  fore- 
finger of  the  patient  and  says  "Up."  The  patient  raises  his  fore- 
arm as  high  as  possible  and  immediately  brings  it  back  again  to 
find  the  finger  of  the  examiner. 

Wrist  from  below  (Fig.  58).  As  the  hand  alone  should  move 
in  this  test,  an  assistant  holds  the  forearm  firmly.  The  examiner 
places  his  forefinger  in  approximately  the  vertical  position,  and 
])laces  the  patient's  finger  in  front  of  it.  The  patient  lowers  his 
finger  as  far  as  possible  and  immediately  brings  it  back  to  find  the 
tinger  of  the  examiner. 

Hip  from  below  (Fig.  59).  The  patient  elevates  the  lower  ex- 
tremity in  a  straight  line  without  bending  the  knee.  The  examiner 
places  his  forefinger  on  the  big  toe  or  on  a  certain  spot  of  the  shoe. 
The  examiner  says  "Down."     The  patient  low^ers  the  foot,  with- 


["f.. 


^^ 


,.^ 


M 

Fig.  £4. — Shoulder  from  the  side. 


\ 


Fig.  55. — Shoulder  to  the  side. 


Fig.  56. — Elbow  from  below. 


'■^t 


Fig.  57. — Elbow  from  above. 


h 


Fi;^ 


^ 


r** 


Fig.  58. — Wrist  from  below. 


ui 


K 


Vl 


Wl 


W: 


VM:': 


¥l 


VI 


I'iG.  59. — Hip  from  below. 


POINTING    J  ESTS  OF  BARANY  177 

out  bending  the  knee,  and  brings  it  back  again  to  find  the  finger  of 
the  examiner. 

Neck  from  beh)w  (Fig.  60).  In  order  to  make  an  accurate  test 
of  any  lateral  movement  of  the  head,  a  pointing  instrument  is  used; 
a  lead-pencil  attached  to  an  ordinary  head-band  is  satisfactory. 
The  examiner  places  his  forefinger  directly  back  of  the  lead-pencil, 
and  says  "Down."  The  patient  bends  the  head  forward  and 
attempts  to  bring  it  back  directly  in  a  straight  line.  The  lead- 
pencil  will  tiien  touch  again  the  finger  of  the  examiner.  In  testing 
the  neck  it  is  essential  that  the  body  shall  not  move.  Therefore,  as 
shown  in  the  pictures,  the  shoulders  of  the  patient  are  held  firmly 
by  an  assistant. 

Trunk  from  below  (Fig.  61).  The  examiner  places  his  finger 
directly  back  of  the  pointing  instrument,  and  says  "Down."  The 
patient  bends  his  entire  body  forward,  and  attempts  to  bring  it 
back  again  in  a  straight  line.  The  pointing  instrument  is  brought 
back  to  touch  the  finger  of  the  examiner. 

In  all  of  these  spontaneous  pointing  tests,  the  normal  individual 
is  invariably  able  to  find  the  finger  of  the  examiner.  If  the  doctor 
does  not  speak  the  language  of  the  patient,  he  can  explain  the  tests 
in  pantomime,  with  the  patient's  eyes  open,  and  then  conduct  the 
tests  with  the  eyes  closed. 

Pointing  Tests  After  Ear-stimulation 

Now  if  the  ear  is  stimulated  either  by  turning  the  patient  or 
douching  his  ear,  and  the  above  tests  are  again  repeated,  the  patient, 
because  of  the  systematized  vertigo  produced  is  no  longer  able  to 
find  the  finger  but  '^past-points."  If  he  feels  he  is  turning  to  the 
left  he  will  ])ast-]ioint  to  the  right;  if  he  feels  he  is  turning  to  the 
right  he  will  past-point  to  the  left. 

Past-pointing  After  Turning 

The  pictures  (Fig.  62)  w^ere  taken  after  turning  the  patient  to 
the  right  with  the  head  upright.  The  pictures  were  taken  from 
above  and  behind  the  patient.     The  first  picture  shows  the  exam- 


#-£ 


f^l 


Fig.  60. — Neck  from  below. 


Patient  bends  head  forward  and  brings  head  backward;  causes  pointing  rest  to  touch 
finger  of  examiner  held  above. 


Fig.  CI. — Trunk  from  below. 


M 


llMl 


i' 


S  s» 


S  # 


\m 


Fig.  62. — After  turning  to  right,  head  30°  forward,  endolymph  movement    in  horizontal  canal  is  to  the 
right;  therefore  patient  past-points  to  right. 


POINTING  TESTS  OF  BARANY  181 

iner  touching  the  patient's  finger  immediately  after  the  chair  has 
been  stopped.  The  patient  gradually  raises  .the  arm  and  on  bring- 
ing it  back  again,  he  is  unable  to  find  the  doctor's  finger  but  past- 
points  to  the  right. 

The  pictures  (Fig.  63)  were  taken  after  turning  the  patient  to 
the  left  with  the  head  upright.  The  first  picture  shows  the  arm 
being  elevated ;  the  patient  continues  to  raise  his  arm  to  the  ver- 
tical position  and  on  coming  back  is  unable  to  find  the  doctor's 
finger  but  past-points  to  the  left. 

Past-pointiistg  Aftee  Caloric  Test 

The  pictures  (Fig.  64)  were  taken  after  douching  the  right  ear 
with  cold  water  wdth  the  head  upright.  After  the  douching,  the 
examiner  has  seized  the  patient's  hand;  the  first  picture  shows  the 
arm  in  the  upright  position.  On  coming  back  to  find  the  finger, 
the  patient  is  unable  to  do  so  but  past-points  to  the  right. 

The  pictures  (Fig.  65)  were  taken  after  douching  the  patient's 
right  ear  witli  the  head  60''  backward.  The  patient  feels  the  doc- 
tor's finger,  raises  the  arm  to  the  vertical  position  and  on  returning 
is  unable  to  find  the  doctor's  finger,  but  past-points  to  the  right. 

The  pictures  (Fig.  66)  were  taken  after  douching  the  left  ear 
with  cold  water.  The  patient  touches  the  doctor's  finger,  elevates 
the  hand  to  the  vertical  position  and  on  returning  is  unable  to  find 
the  examiner's  finger  but  past-points  to  the  left. 

The  pictures  (Fig.  67)  were  taken  after  douching  the  left  ear 
with  cold  water  with  the  head  back  60°.  The  patient  touclies  the 
doctor's  finger,  raises  the  hand  to  the  vertical  position  and  on 
returning  is  unable  to  find  the  finger  but  past-points  to  the  left. 

ExPLANATIOX   OF   PaST-POINTING 

Past-pointing  is  not  an  ORY-rearfion.  Ear  stimulation  produces 
two  reactions  and  two  only.  They  are  (1)  nystagmus,  and  (2) 
vertigo. 

Ear  stimulation  causes  a  pulling  of  the  eyes ;  this  is  easily  under- 


wn 


t 


I 


i^ 


% 


Fig.  63. — After  turning  to  left,  patient  past-points  to  left. 


flk'^'                         ^^^H 

Y:!'    *'. 


,W 


UUf 


w  * 


1^ 


m 


iif 


■/  f 


w  ^ 


u 


m 


04.  — After    douching    right    ear,    water    68°,    head    30"    forward,    stimulating    vertical    canals,    the 
endolymph  movement  is  down  to  the  right;  therefore  patient  past-points  to  right. 


'Mi 


Fig.  65. — After  douching  right  ear,  water  08°,  head  60°  back,  endolymph  movement  in  horizontal  canal 
is  down  to  the  right;  therefore  patient  past-points  to  right. 


«  m 


*  m 


#  ^ 


?  w 


?  w 


*  m 


! 


f.w 


^  w 


Fig.   66.— After  douching  left  ear,  water  68°,  the  endolymph  movement  is  down  to  the  left;  therefore  patient 

past-points  to  the  left. 


'  fp 


-  \-^ 


l'"lG.   07. — After  douching  left  ear,  head  00°  back,  emh, lymph  movement  in  left  horizontal  canal  is  1     left; 

therefore  patiint  past-points  to  left. 


POINTING  TESTS  OF  BARANY  187 

stood  as  a  simple  reflex.  Tlie  afferent  sensory  impulse  is  from  the 
semicircular  canals  to  the  eye-muscle  nuclei  in  the  pons ;  the  effer- 
ent UiOtor  impulse  is  from  the  eye-muscle  nuclei  to  the  eye  muscles 
themselves.  This  reflex  exists  by  itself  and  has  no  part  in  the 
causation  of  past-pointing.  The  other  reaction  to  ear  stimulation 
is  vertigo.  It  is  not  a  reflex;  it  is  a  subjective  disturbance  of  the 
cerebral  cortex  due  to  sensory  impulses  received  directly  from 
the  ear. 

Pointing,  on  the  other  hand,  is  a  cerebral  motor  act.  Neither 
turning  a  person  in  a  chair  nor  douching  his  ears  causes  him  to 
past-point.  He  is  asked  to  raise  his  arm  and  then  bring  it  back  to 
find  t.ie  finger.  Before  ear  stimulation  he  is  able  to  find  the  finger; 
after  ear  stimulation  he  is  unable  to  find  the  finger  because  of  the 
vertigo.  It  may  be  regarded  as  a  law  of  the  ear-tests  that  where 
there  is  no  vertigo  there  is  no  past-pointing.  Vertigo  is  the  pri- 
mary reaction;  past-pointing  is  a  secondary  manifestation.  This 
is  contrary  to  the  general  conception  that  past-pointing  is  due  to  a 
cerebellar  pull  of  the  arm  to  one  side,  in  the  same  way  that  the 
eyes  are  drawn  to  one  side  by  the  stimulus  from  the  labyrinth. 
Past-pointing  is  not  a  cerebellar  function ;  it  is  cerebral.  Spontane- 
ously, the  cerebral  mandate  is  to  find  the  finger  at  the  exact  point 
where  it  is ;  after  ear-stimulation  the  cerebral  mandate  is  to  find  the 
finger  at  a  point  where  the  cerebrum  now  conceives  it  to  be.  In 
either  case  the  cerebellum  through  its  synergic  function,  carries 
out  the  cerebral  command  with  accuracy;  the  cerebellum  inhibits 
wayward  movement  and  by  so  doing  makes  possible  the  accurate 
co-ordinate  act. 

That  past-pointing  is  not  due  to  a  cerebellar  pull  can  be  proven 
by  the  following  five  simple  experiments  : 

(1)  Anyone  wishing  to  understand  this  phenomenon  need 
merely  have  himself  turned  in  the  chair.  After  he  is  turned  to 
the  right  he  has,  on  stopping,  a  subjective  sensation  of  turning 
to  the  left.  He  feels  that  he  is  leaving  the  examiner  behind  and 
for  this  reason  he  consciously  and  deliberately  points  to  the  right, 
where  he  conceives  the  finger  now  to  be.  If  after  the  usual  past- 
pointing,  the  examiner's  finger  is  moved  out  to  meet  that  of  the 


188  EQUILIBRIUM  AND  VERTIGO 

exaniiiied,  and  if  the  pointing  is  then  repeated,  he  past-points  still 
further  to  the  right.  He  would  continue  perhaps  to  the  completion 
of  an  entire  circle  in  his  chase  for  the  seemingly  moving  linger, 
but  for  the  limitations  enforced  by  his  seating.  After  experiencing 
this  test,  anyone  is  convinced  that  he  has  past-pointed  Ijecause  of 
his  vertigo. 

(2)  An  intelligent  su))ject  who  knows  that  he  would  natur- 
tdly  ])ast-point  after  stimulation,  can  voluntarily  by  a  careful 
mental  calculation,  correct  the  past-pointing  and  deliberately  point 
in  the  other  direction.  If  he  knows  that  he  would  naturally  point 
twelve  inches  toward  the  right,  he  can  deliberately  point  twelve 
inches  toward  the  left  and  in  this  way  may  be  able  to  touch  the 
finger.  This  proves  conclusively  the  mental  control  over  the 
direction  of  the  pointing. 

(3)  If  the  duration  of  vertigo,  after  turning,  is  timed  with  a 
stop-watch,  and  then  a  second  test  is  innnediately  repeated,  and 
follow^ed  by  past-pointing,  the  duration  of  the  past-pointing  also 
being  recorded  by  the  stop-watch,  it  will  be  found  that  the  duration 
of  the  vertigo  and  the  duration  of  the  past-pointing  are  the  same. 
The  average  length  of  time  in  which  the  vertigo  continues  is  26 
seconds  and  the  average  length  of  time  in  which  the  past-pointing 
continues  is  also  26  seconds. 

(-1-)  S.  A.  Brumm  has  demonstrated  that  after  turning,  if  the 
individual  is  asked  to  move  his  finger  up  and  down  in  a  vertical 
plane,  he  is  able  to  do  so  and  does  not  deviate  to  the  side.  He  merely 
moves  his  finger  up  and  down  in  front  of  him  in  the  vertical  plane 
which  he  conceives  to  be  revolving  with  him.  If,  however,  he 
touches  some  external  object,  and  then  tries  to  find  it  again,  he 
then  feels  that  he  is  leaving  that  object  behind  him  and  past-points 
in  that  direction. 

(5)  Turning  to  the  right  with  the  head  back  60"  produces  past- 
pointing  to  the  right ;  turning  to  the  right  with  the  head  forward 
120°  also  produces  past-pointing  to  the  right.  If  past-pointing 
were  due  to  a  cerebellar  pull  this  result  would  obviously  be  im- 
possible ;  turning  with  the  head  backward  and  turning  with  the 
head   forward   ]iroduce   diametrically   opposite   stimuli.     If  past- 


POINTING  TESTS  OF  BARANY  189 

pointing  were  a  cerebellar  reflex,  the  individual  would  in  one  in- 
stance point  to  the  right  and  in  the  other  instance  point  to  the 
left.  The  past-pointing  which  occurs  to  the  right  in  both  instances, 
is  because  the  cerebral  centres  receive  the  same  impression  of 
vertigo — that  the  body  is  turning  to  the  left — no  matter  in  what 
position  the  head  may  be  placed. 

The  pictures  (Figs.  68,  G9)  show  the  patient  being  turned 
to  the  right  with  the  head  back  60\  The  examiner  then  takes 
the  patient's  hand  and  has  him  touch  the  linger.  The  patient  raises 
the  arm  to  the  vertical  position  and  on  coming  back  is  unable  to 
find  the  finger  but  past-points  to  the  right. 

The  pictures  (Figs.  70,  71)  show  the  patient  being  turned  to 
the  left  with  the  head  60^  back.  On  stopi)ing  the  chair,  the  exam- 
iner seizes  the  patient's  finger.  The  patient  raises  the  arm  to  the 
vertical  position  and  on  bringing  it  back  is  unable  to  find  the  finger 
but  past-points  to  the  left.  An  individual  will  always  past-point 
to  the  right  when  he  is  turned  to  the  right,  no  matter  whether 
the  head  is  forward,  upright  or  back.  He  will  past-point  to  the  left 
when  he  is  turned  to  the  left,  no  matter  whether  the  head  is  for- 
ward, upright  or  back.  It  is  evident  therefore,  that  past-pointing 
is  not  a  reflex  but  is  a  deliberate  cerebral  act. 

Summarizing  therefore,  the  cerebellum  plays  only  a  partial 
role  in  the  large  mechanism  of  the  pointing.  The  kinetic-static 
sense,  the  arthrodial  sense,  tactile,  auditory  and  visual  impressions 
and  memory  all  combine  to  inform  the  individual  of  the  position 
of  an  external  object.  The  motor  areas  of  the  cerebral  cortex  then 
send  impulses  to  the  arms ;  the  function  of  the  cerebellum  is  merely 
in  controlling  the  execution  of  the  cerebral  mandate.  If  this  be 
erroneous,  because  of  the  vertigo,  past-pointing  results. 

Tracts  for  Pointing 

The  paths  for  the  pointing  and  the  paths  for  the  past-pointing 
are  one  and  the  same.  The  mechanism  of  the  pointing  is  the  same 
whether  the  individual  attempts  to  find  the  finger  where  it  really 
is,  or  when  he  points  in  a  false  direction  because  of  his  vertigo. 


t 


^-.L 


Fig.  68. — Turning  to  the  right,  head  bar-k  60° 


\  t. 


i 


;i-  U 


a 

11 

B 

jy 

S 

^^■^fl^^jB 

1^ 

11 

M 

BJ 

1 

'& 

p^ 

V, 

B'-l 

i 

^Hl^^'^'s 

! 

0 

JB.    <«      'fl 

1 

Fig.  69. — Produres  pnst-pointing  to    the  right. 


Fig.   70.— Turning  to  the  left,  head  60°  back,  causes  endolymph  movement  to  the  left. 


13 


Fig.   71.— Therefore  patient  past-points  to  the  left. 


19-i 

RIGHT 


EQUILIBRIUM  AND  VERTK.O 


LEFT 


MOTOR  CENTRE         A'^ 
UPPER  EXTREMITY 


CROSSED 
PYRAMIDAL  TRACT 


Fio.   72. — Pyramidal  tract  becoming  the  crossed  pyramidal  tract,    ("power"  tract). 


POINTING  TESTS  OF  BARANY 


195 


MOTOR    CENTRE 


Fig.  73. — Cerebro-cerebellospinal  tract,  ("accuracy"  tract). 


196 


EQUILIBRIUM  AND  VERTKiO 


111  the  previous  ('liai)ter  were  shown  the  ])atlis  of  the  sensory  im- 
pulses from  the  ear  to  the  cerebral  cortex  producing  vertigo.  The 
paths  for  pointing,  on  the  other  hand,  are  purely  motor.  They  be- 
gin in  the  motor  area  of  the  cerebral  cortex  and  end  in  the  periph- 


Right 


Left 


Fig.   74. — Pointing    tracts:    "P"    "Power    tract,"    pyramidal    tract,    decussating    in    medulla    oblongata. 
"A"  "Accuracy  tract,"  cerebro-cerebello-spinal  tract,  decussating  in  pons. 

eral  distribution  to  those  particular  muscles  which  are  employed 
in  tliQ  pointing  tests.     These  paths  are  two: 

(1)   The  pyramidal  tract.    This  may  be  s])oken  of  as  the  power 
tract.     It  supplies  the  motor  force  for  pointing. 


POINTING  TESTS  OF  BARANY 


197 


(2)  The  cerebro-cerebello-spinal  tract.  This  may  be  termed  the 
accuracy  tract.  It  is  by  this  path  that  the  cerebellum  is  able  to 
exercise  its  synergic  or  inhibitory  influence.  The  pyramidal  tract 
alone  would  be  able  to  supply  the  necessary  energy  to  raise  the 
arm  up  and  to  bring  the  arm  down.  But  it  is  the  cerebellum  that 
enables  the  arm  to  point  accurately  and  find  the  finger.  Just  liow 
this  is  accomplished  may  be  explained  in  the  following  way :  In  the 
cerebellar  cortex  are  separate  centres,  one  for  tlie  outward  pointing 


'cerebellum 


Fig.   75. — Pointing   tracts.     "P"    "Power   tract" — pyramidal    tract,    decussating   in    medulla    oblongata. 
"A"  "Accuracy  tract" — cerebro-cerebello-spinal  tract,  decussating  in  pons. 


and  one  for  the  inward  pointing  of  different  joints.  As  the  arm  de- 
scends to  find  the  finger,  if  it  tends  to  point  outward,  the  inward- 
pointing  centre  restrains  this  aberrant  movement  and  draws  it  back 
to  its  proper  course.  If  it  tends  to  point  inward,  the  outward-point- 
ing centre  of  the  cerebellum  brings  it  back  to  its  proper  course. 

Consulting  the  diagram  (Fig.  72)  the  pyramidal  tract  for  the 
pointing  of  the  right  upper  extremity  starts  in  the  left  cerebral 
cortex  at  tlie  motor  centre  of  the  upper  extremity.    Traversing  the 


198  EQUILIBRIUM  AND  VERTIGO 

internal  capsule  it  passes  through  the  left  cerebral  crus,  the  left 
side  of  the  pons,  and  decussates  in  the  medulla  oblongata  to  the 
right  side,  becoming  the  crossed  pyramidal  tract.  Passing  down 
the  right  side  of  the  spinal  cord  the  fibres  enter  the  brachial  plexus 
and  are  distributed  to  the  muscles  of  the  right  upper  extremity. 

The  cerebro-cerebello-spinal  tract  (Fig.  73),  for  the  pointing 
of  the  right  upper  extremity,  also  begins  in  the  left  cerebral 
cortex  in  the  motor  centre  of  the  upper  extremity.  Traversing 
the  internal  capsule  it  passes  through  the  left  crus  cerebri  into 
the  left  side  of  the  pons  where  it  probably  decussates  to  the 
opposite  side  and  enters  the  dentate  nucleus  of  the  cerebellum 
through  the  right  middle  cerebellar  peduncle.  The  dentate  nucleus 
is  a  relay  station  for  fibres  to  and  from  the  cerebellar  cortex. 
Continuing  from  the  dentate  nucleus  the  pathway  passes  through 
the  right  inferior  cerebellar  peduncle  through  the  right  side  of  the 
medulla  oblongata  and  spinal  cord  to  enter  the  brachial  plexus 
through  Avhich  it  also  is  distributed  to  the  muscles  of  the  right 
upper  extremity. 

Figure  74  combines  the  two  pathways  in  one  diagram. 

Figure  75  represents  a  lateral  view  of  the  two  pathways ;  the 
pyramidal  or  "power"  tract  is  shown  decussating  in  the  medulla 
oblongata  and  the  cerebro-cerebello-spinal  or  "accuracy"  tract  is 
shown  decussating  in  the  pons. 


Planes  of  Past-pointing 

Past-pointing  can  occur  in  three  planes  of  space — the  horizontal, 
the  frontal  and  the  sagittal.  The  plane  of  the  past-pointing  is 
always  in  the  plane  of  the  vertigo  producing  it ;  the  direction  of  the 
past-pointing  is  naturally  directly  opposite  to  the  direction  of 
the  vertigo  producing  it.  After  turning  an  individual  with  the 
head  upright,  the  horizontal  canals  produce  a  sensation  of  turning 
in  the  horizontal  plane.  Past-pointing,  therefore,  occurs  in  the 
horizontal  plane  to  the  right  or  to  the  left  in  the  direction  opposite 
to  the  subjective  sensation  of  turning.     For  instance,  after  turning: 


POINTING  TESTS  OF  BARANY  199 

to  the  right  the  patient  stops,  feels  that  he  is  moving  to  the  left 
away  from  the  finger,  and  therefore  past-points  to  the  right. 

Now  if  the  head  is  inclined  120°  forward,  the  turning  sensa- 
tion is  in  the  frontal  plane  of  the  head.  If  the  head  is  kept  in  this 
position,  the  frontal  plane  is  parallel  to  the  plane  of  the  floor. 
Therefore  the  sensation  of  turning  is  the  same  as  when  he  was 
turned  with  the  head  upright.  If  he  has  been  turned  to  the  right  he 
feels  that  he  is  turning  to  the  left  and  therefore  past-points  to  the 
right.  Now  if  after  turning  the  head  is  raised,  the  frontal  plane 
then  assumes  a  position  at  a  right  angle  to  the  floor.  The  sub- 
jective sensation  therefore  is  one  of  falling  to  the  left  in  the  frontal 
plane.  As  he  feels  that  he  is  falling  to  the  left  he  past-points  to 
the  right.  It  will  be  noted  that  the  result  is  the  same — after  turning 
with  the  head  forward,  he  will  past-point  to  the  right  whether  the 
head  is  kept  iur  the  forward  position  or  brought  upright  after  the 
turning. 

Now  if  the  individual  has  been  turned  with  the  head  inclined 
backward  60°,  on  stopping,  the  turning  sensation  is  also  in  the 
frontal  plane.  If  the  head  is  kept  in  this  position,  the  frontal 
plane  of  the  head  is  parallel  to  the  floor.  Therefore  the  sensation 
of  turning  is  the  same  as  when  he  was  turned  with  the  head  upright. 
If  he  has  been  turned  to  the  right  he  feels,  therefore,  that  he  is 
going  to  the  left  and  consequently  he  past-points  to  the  right. 
If,  however,  after  turning  to  the  right  with  the  head  back  the 
head  is  brought  upright,  the  frontal  plane  assumes  a  position  at  a 
right  angle  to  the  floor.  Immediately  the  previous  sensation  of 
turning  to  the  left  is  changed  into  a  sensation  of  falling  to  the 
right.  As  the  individual  feels  he  is  falling  to  the  right,  he  past- 
points  to  the  left.  It  will  be  noted  that  bringing  the  head  upright 
after  turning  with  the  head  back  causes  a  complete  reversal  of  the 
past-pointing;  if  the  head  is  kept  back,  he  past-points  to  the  right, 
whereas  if  the  head  is  brought  upright  he  past-points  to  the  left. 
The  explanation  is  simple  and  strictly. according  to  rule.  The  past- 
pointing  is  in  the  direction  opposite  to  the  vertigo.  We  always  con- 
sider vertigo  in  terms  of  our  relation  to  what  is  in  front  of  us,  or 
below  us.    After  the  individual  has  been  turned  to  the  right  with  the 


.V  -1 


^^-*0 


■-n 


•J* 


Fig.   "(i. — Turning  to  left  with  head  incHned  toward  rijilit  shoulder,  causes  endolyniph  movement  downward 

in  sagittal  plane. 


Fig.   77. — Therefore  patient  past-points  below 


^2(n  EQUILIBRIUM  AND  VERTIGO 

head  back,  the  endolympli  movement  is  to  the  rigJtt  in  rehition  to 
objects  in  front  of  him.  When,  however,  the  head  is  brought 
ujiright,  this  same  endolymi)h  movement  is  to  the  left  in  relation  to 
objects  above  him.  His  sensation  of  vertigo  is  therefore  imme- 
diately reversed  when  the  head  is  brought  upright.  Anyone  tested 
in  this  way  at  once  recogiiizes  this  reversal  in  the  vertigo. 

Now  if  the  head  is  inclined  toward  the  shoulder,  turning  pro- 
duces the  subjective  sensation  of  movement  in  the  sagittal  plane 
of  the  head.  If  the  head  is  maintained  in  this  position,  the  sagittal 
plane  of  the  head  is  parallel  to  the  floor;  the  individual  therefore 
past-points  in  the  horizontal  plane,  to  the  right  or  the  left.  If, 
however,  the  head  is  brought  upright,  the  sagittal  plane  of  the  head 
is  then  at  right  angles  to  the  floor;  the  individual  therefore  has  a 
subjective  sensation  of  falling  in  the  sagittal  plane — forward  or 
backward.  Consequently  he  past-points  below  or  above  the  finger 
of  the  examiner,  in  the  sagittal  plane. 

Figures  76  and  77  show  turning  to  the  left  with  the  head  in- 
clined to  the  right  shoulder.  The  plane  of  the  turning  is  therefore 
in  the  sagittal  plane  of  the  head.  At  the  end  of  the  turning  the 
patient  raises  her  head  to  the  vertical  position,  the  examiner  has 
the  patient  feel  his  finger,  move  the  arm  out  to  the  side ;  on  return- 
ing to  the  median  line  the  patient  is  unable  to  find  the  examiner's 
finger  but  past-points  below  it. 


Table  or  Past-pointing  After  Turning 

Turning  to  the  right  with  the  head  upright  produces  past-pointing  to  the  right. 

Turning  to  the  left  with  the  head  upright  produces  past-pointing  to  the  left. 

Turning  to  the  right  with  the  head  back  60°  produces  past-pointing  to  the  right. 

Turning  to  the  left  with  the  head  back  60°  produces  past-pointing  to  the  left. 

Turning  to  the  right  with  the  head  forward  120°  produces  past-pointing  to  the 
right. 

Turning  to  the  left  with  the  head  forward  120°  produces  past-pointing  to  the 
left. 

Turning  to  the  right  with  the  head  inclined  toward  the  right  shoulder  and 
then  bringing  head  upright  produces  past-pointing  upward. 

Turning  to  the  left  w4th  the  head  inclined  toward  the  right  shoulder  and  then 
bring^ing  head  upright,  produces  past-pointing  downward. 


POINTING  TESTS  OF  BARANY  203 

Turning  to  the  right  with  the  head  inclined  toward  the  left  shoulder  and  then 
bringing  head  upright,  produces  a  past-pointing  downward. 

Turning  to  the  left  with  the  head  inclined  toward  the  left  shoulder  and  then 
bringing  head  upright,  produces  a  past-pointing  upward. 


Table  of  Past-pointing  After  Douching 

Douching  the  right  ear  ^\dlh  the  head  upright,  water  68°,  produces  past- 
pointing  to  the  right. 

Douching  the  left  ear  with  the  head  upright,  water  68°,  produces  past-point- 
ing to  the  left. 

Douching  the  right  ear,  head  back  60°,  water  6S°.  produces  past-pointing  to 
the  right. 

Douching  the  left  ear,  head  back  60°,  water  68°,  produces  past-pointing  to 
the  left. 

Douching  the  right  ear  with  the  head  forward  120°,  water  68°,  produces  past- 
pointing  to  the  left. 

Douching  the  left  ear  with  the  head  forward  120°,  water  68°,  produces  past- 
pointing  to  the  right. 

Douching  the  right  ear  with  the  head  upright,  water  112°,  produces  past- 
pointing  to  the  left. 

Douching  the  left  ear  with  the  head  upright,  water  112°,  produces  past-point- 
ing to  the  right. 

Douching  the  right  ear,  head  back  60°,  water  112°,  produces  past-pointing  to 
the  left. 

Douching  the  left  ear,  head  back  60°,  water  112°,  produces  past-pointing  to 
the  right. 

Douching  the  I'ight  ear,  head  forward  120°,  water  112°,  produces  past-pointing 
to  the  right. 

Douching  the  left  ear,  head  fonvard  120°,  water  112°,  produces  past-pointing 
to  the  left. 

Falling 

It  may  be  noted  at  this  point  that  the  phenomenon  of  '^ falling" 
after  ear-stimulation  may  be  regarded  as  a  past-pointing  of  the 
entire  body.  The  patient  falls  because  of  the  vertigo,  and  not 
because  his  body  is  drawn  to  one  side  or  the  other  by  the  ear- 
stimulation.  Falling  is  naturally  not  in  evidence  when  the  sub- 
jective sensation  is  one  of  movement  in  the  horizontal  plane ;  the 
individual  feels  that  he  is  being  rotated  on  his  own  vertical  axis 
and  there  is  therefore  no  tendencv  to  fall  either  to  the  right  or  to  the 


^?s..'^ 


li«W,  5* 


M4«- 


V 


M 


l^M 


^ 


^^ 


^^. 


i^^ 


Fig.  78.— Turning  to  right,  head  120°  forward,  causes  endolymph  movement  to  the  right  in  the  frontal  plane. 


tm^- 


"■**"i 


Fig.  79. — Therefore  on  sitting  up,  patient  falls  to  the  right  in  the  frontal  plane. 


^ 


<^ 


Fig.  80. — Turning  to  right  with  head  60°    back, 


I 


Fir.  81. — Will  produce  falling  to  left  when  head  is  raised  to  upright  position. 


f^' . 


»*w 


"^  1 


^^>-v« 


1^  s 


,^K,j5f, 


*^^^Srsy-   ^^ 


-is!*^ 


■^^     * 


^1 


:#W^ 


"^ 


Fk;.  S2.— Turning  to  left.  Lead  120°  forward,  causes  endolymph 


movement  to  the  left  in  the  frontal  plane. 


"^ 


^w 


-%-M^ 


iV*"  _ 


-ii^ 


14 


Fig.   83.— Therefore  on  sitting  up,  patient  falls  to  the  left  in  "the  frontal  plane. 


oio  EQUILIBRIUM  AND  VERTIGO 

left  or  front  or  back.  If,  however,  tlie  subjective  sensation  is  one  of 
turning  in  the  frontal  plane,  he  tends  to  fall  either  to  one  side  or  the 
other.  If  tlie  subjective  sensation  is  one  of  movement  in  the  sagit- 
tal plane,  he  tends  to  fall  either  forward  or  backward. 

The  pictures  (Figs.  78,  79)  show  the  patient  being  turned  to  the 
right  with  the  head  forward;  after  the  chair  is  stopped  the  patient 
raises  his  head  to  the  vertical  position  and  falls  directly  to  the 
right.  When  the  head  is  in  the  upright  position,  the  endolymph 
movement  is  to  the  right  and  therefore  the  falling  is  to  the  right. 
In  detail,  endolymph  movement  to  the  right  causes  a  subjective  sen- 
sation of  falling  to  the  left,  and  therefore  the  i)atient  falls  to  the 
right. 

The  pictures  (Figs.  8U,  81)  show  the  patient  being  turned  to  the 
right  with  the  head  back;  after  the  chair  is  stopped  the  patient 
brings  the  head  forward  to  the  vertical  position  and  falls  directly 
to  the  left.  With  the  head  in  the  upright  position  the  endolymph 
movement  is  to  the  left  and  the  patient  therefore  falls  to  the  left. 
In  detail,  the  endolymph  movement  to  the  left  causes  a  subjective 
sensation  of  falling  to  the  right  and  therefore  the  patient  falls  to 
the  left. 

The  pictures  (Figs.  82,  83)  show  the  patient  being  turned  to 
the  left  with  the  head  forward ;  after  the  chair  is  stopi)ed  the  patient 
raises  the  head  to  the  upright  position  and  immediately  falls  to  the 
left,  because  the  endolymph  movement  is  to  the  left. 

All  of  these  falling  movements  to  the  right  and  to  the  left  have 
occurred  in  the  frontal  ]ilane  because  turning  with  the  head  forward 
or  backward  stimulates  the  vertical  canals  in  the  frontal  plane. 
Falling  in  the  sagittal  plane  is  necessarily  produced  by  stimulation 
of  the  vertical  canals  in  the  sagittal  plane. 

The  pictures  (Fig.  84)  show  the  patient  being  turned  to  the  left 
with  the  head  inclined  toward  the  right  shoulder.  The  plane  of 
the  turning  is  therefore  in  the  sagittal  plane  of  the  head.  When 
the  chair  is  stopped,  the  patient  brings  the  head  to  the  upright  posi- 
tion and  immediately  falls  forward  in  the  sagittal  plane. 


dK^ 


^^ks- 


^^v-  % 


4jK^%,,^,       ^jk 


^  % 


jnIi# 


Jwl# 


J^m 


M       '  1^ 


Fig.  84.— Turning  to  left,  head  inclined  toward  right  shoulder,  causes  endolymph  movement  downward  in 
sagittal  plane.     1  herefore  patient  falls  forward. 


^U  EQUILIBRIUM  AND  VERTIGO 

Table  of  Falling  Ai?^ter  Turning 

Turning  to  the  nglit.  head  forward  120°,  and  sitting  upright,  produces  falling 
ro  the  right. 

Turning  to  the  left,  head  forward  120'.  and  sitting  upriglit,  produces  falling 
to  the  left. 

Turning  to  the  riglit,  licad  l)ack  {)0°,  and  sitting  u|)rigbt,  produces  falling 
to  the  left. 

Turning  to  the  left,  head  hack  60°,  and  sitting  ui)riglit.  produces  falling  to 
the  right. 

Turning  to  the  right,  head  inclined  toward  tlie  right  shoulder,  and  bringing 
head  upright,  produces  falling  backward. 

Turning  to  the  left,  bead  inclined  toward  the  right  shoulder,  and  bringing 
head  upright,  i:>roduces  falling  forward. 

Turning  to  the  right,  head  inclined  toward  the  left  shoulder,  and  bringing 
head  upright,  produces  falling  forward. 

Turning  to  the  left,  head  inclined  toward  the  left  shoulder,  and  bringing  the 
head  upright,  produces  falling  backward. 


Table  of  Falling  After  Douching 

Douching  right  ear,  head  upright,  water  68°.  produces  falling  to  the  right. 
Douching  left  ear,  head  upright,  water  68°,  produces  falling  to  the  left. 
Douching  right  ear,  head  back  60°,  water  68°,  produces  falling  to  the  right. 
Douching  the  left  ear.  head  back  60°,  water  68°.  produces  falling  to  the  left. 
Douching  right  ear,  head  upright,  Avater  112°,  jiroduces  falling  to  the  left. 
Douching  left  ear,  head  upright,  water  112°,  produces  falling  to  the  right. 
Douching  right  ear,  head  back  60°,  water  112°,  produces  falling  to  the  left. 
Douching  left  ear,  head  back  60°,  water  112°,  produces  falling  to  the  right. 

It  is  not  iK'cessai-y  to  commit  to  memory  any  one  of  these 
responses.  Under  all  circumstances  l)otli  tlie  past-pointing  and  the 
fallivr/  are  ahcai/s  in  tlic.  directwu  of  the  eiifloJifiii pli  movement. 


CHAPTER   XVIII 

TECHNIC    OF    EXAMINATION    OF    THE    AUDITORY    APPA- 
RATUS AND  OF  THE  VESTIBULAR  APPARATUS 

In  the  last  three  chapters  we  have  discussed  nystagmus,  vertigo, 
and  the  pointing-tests  as  such;  we  are  therefore  in  a  position  to 
understand  the  object  of  the  examinations  and  can  now  take  up  the 
technic.  So  little  has  been  known  of  the  physiology  of  the  vestibular 
labyrinth  until  comparatively  recent  times  that  the  lack  of  a  well- 
established  technic  of  its  examination  is  not  surprising.  Until 
recently,  all  examinations  of  the  labyrinth  were  carried  out  with 
the  sole  purpose  of  determining  its  own  integrity.  Such  tests  were 
sufficient  for  the  aural  surgeon,  who  was  called  upon  merely  to 
decide  whether  or  not  to  operate  on  the  "end-organ."  With 
the  development  of  the  idea  that  the  labyrinth  is  only  one  portion 
of  the  vestibular  apparatus  came  the  realization  that  this  whole 
apparatus  was  being  interrogated  at  the  same  time  that  the  in- 
ternal ear  itself  was  being  tested,  and  also  that  an  intelligent  in- 
terpretation of  the  phenomena  obtained  by  such  tests  can  give  the 
examiner  an  insight  into  the  condition  of  those  various  brain  paths 
and  brain  centres  in  relation  with  the  internal  ear.  Thus,  when  a 
known  stimulus  is  applied  to  the  labyrinth,  any  response  obtained 
therefrom,  be  it  nystagmus  or  vertigo,  indicates  not  only  a  func- 
tionating and  reacting  labyrinth,  but  also  intact  path^vays  from 
the  labyrinth  to  the  brain  centres  responsible  for  those  reactions. 
Conversely,  the  non-appearance  of  any  of  the  normal  responses 
to  stimulation  indicates  an  interruption  at  some  point  along  the 
particular  pathway  that  fails  to  produce  that  particular  response. 
This  made  it  evident  that  the  old  technic  of  examination  was  in- 
adequate and  Barany  elaborated  a  new^  technic  which  created  a 
standard  for  these  examinations.  In  preceding  chapters  we  have 
shown  that  the  fibres  from  the  horizontal  semicircular  canal  have 

213 


>U  EQUILIBRIUM  AND  M:RTIG() 

au  eiilirely  separate  iiitiacraiiial  course  from  those  of  the  vertical 
semicircular  canals;  and  wliiU'  all  fibres  concerned  in  vertigo  go  to 
the  cerebellum,  we  cousiilci-  tliat  those  from  the  horizontal  canal 
reach  it  by  way  of  the  inferioi-  cerebellar  peduncle,  while  those 
from  the  vertical  canals  go  by  way  of  the  middle  cerebellar  petluncle. 
Further,  we  have  shown  that  nystagmus  and  vertigo  are  distinct 
and  sei»ai'ate  })lienomena;  also  that  [)ast -pointing  is  not  a  "cere- 
bellar i)nll,"  but  is  a  cerebral  ])lienomenon  exclusively  and  depends 
entirely  on  the  vertigo  induced  by  the  ear  stimulation.  Barany's 
technic,  elaborated  before  such  a  differentiation  was  demonstrated, 
deals  with  the  labyrinth  as  a  whole,  whereas  from  this  new  view- 
point, it  at  once  becomes  evident  how  important  it  is  to  examine 
cacli  set  of  canals  separately  and  furthermore  to  analyze  separately 
the  nystagmus,  vertigo  and  past-i>ointing  produced  by  stimulation 
of  each  set  of  canals.  Above  all,  it  is  of  prime  importance  that  if  the 
data  ol)tained  from  such  an  examination  are  to  be  relied  on,  the 
technic  must  be  accurate,  complete  and  painstaking.  Those  uncon- 
vinced of  the  value  of  these  tests  must  ascribe  their  difficulty  to 
laxity  in  the  methods  of  conducting  them.  An  examination  of  the 
labyrinth,  although  the  underlying  principles  are  by  no  means 
complex,  nevertheless  requires  the  determining  of  so  much  data 
that  it  is  an  almost  hopeless  task  wdien  examining  a  patient  to 
attempt  to  write  down  all  the  findings  in  ivords.  The  beginner 
especially  is  bewdldered  by  the  apparently  endless  amount  of  data. 
All  who  have  done  this  work  realize  what  a  nuisance  it  is  to  keep 
haphazard  records,  on  slips  of  paper  perhaps,  of  the  results  ob- 
tained from  the  various  vestibular  tests.  For  example — "  On 
turning  to  the  right,  the  patient's  nystagmus  was  horizontal  to  the 
left  of  so  many  seconds,  but  his  past-pointing  was  so  much  for  the 
right  arm  to  the  right,  and  so  much  for  the  left  arm  to  the  right, 
etc.,  etc."  We  all  know  how^  hopeless  it  is  to  attempt  the  analysis 
of  a  case  from  such  records.  To  obviate  this  difficulty,  Ave  grad- 
ually formulated  the  accompanying  chart,  in  which  all  the  tests 
are  outlined  in  the  order  in  which  they  are  usually  undertaken,  and 
wdiich  is  so  arranged  that  when  properly  filled  in,  it  shows  all  the 
vestibular  data  by  a  single  glance  at  one  page.     If  this  chart  is 


AUDITORY  AND  VESTIBULAR  APPARATUS  215 

filled  ill,  it  will  represent  a  fairly  complete  exaiiiiiiatioii  of  the 
labyrinth,  and  will  contain  the  findings  in  practically  all  the  essen- 
tial tests.  We  think  this  chart  is  of  so  much  help  in  the  examina- 
tion and  diagnosis  of  a  case,  that  it  is  actually  a  part  of  the  technic, 
and  we  will  therefore  describe  it. 

One  side  of  the  chart  is  devoted  to  miscellaneous  details  or 
such  routine  matters  as  are  found  on  any  chart,  with  particular 
emphasis  on  examination  of  the  cochlea.  The  other  side  is  devoted 
exclusively  to  the  vestibular  tests,  of  which  there  are  three  sub- 
divisions— spontaneous,  turning  and  caloric.  There  is  a  complete 
column  for  the  "nystagmus"  and  another  complete  column  for 
"pointing";  this  enables  us  to  study  the  nystagmus  as  such  by 
running  the  eye  down  the  column  to  the  left,  showing  first  the 
spontaneous  nystagmus,  then  the  nystagmus  after  turning,  and 
then  after  the  caloric  test.  In  the  same  way  the  pointing  tests  can 
be  studied  as  such  by  following  right  down  the  page,  first  the  spon- 
taneous, then  those  after  turning  and  then  those  after  douching. 

Asa  further  aid  there  is  a  space  reserved  on  the  chart  for  sum- 
marizing the  findings  obtained  after  each  form  of  examination.  As 
we  always  look  for  the  following  phenomena — nystagmus,  vertigo, 
past-pointing  and  falling — they  are  indicated  concisely  one  under- 
neath the  other  in  each  of  the  three  subdivisions.  The  examiner, 
after  he  has  turned  the  patient,  simply  summarizes  by  indicating 
"nystagmus  normal"  or  "absent";  vertigo  "normal"  or  "sub- 
normal," or  "exaggerated"  or  "absent"  as  the  case  may  be,  and 
so  on  in  the  same  way  under  the  other  headings.  When  the  chart 
is  filled  in  as  we  have  indicated  and  an  analysis  of  the  case  at- 
tempted for  the  purpose  of  diagnosis,  all  the  examiner  need  do  is 
to  look  at  these  different  summaries  under  the  three  main  sub- 
divisions to  get  a  bird's-eye  view,  as  it  were,  of  the  whole  case. 

We  will  imagine  we  are  examining  a  patient  and  conducting  the 
tests  step  by  step  with  the  aid  of  the  chart.  The  "miscellaneous" 
side  of  the  chart  is  filled  in  first,  taking  up  every  heading  indicated 
and  filling  it  in  with  appropriate  information.  "Diagnosis"  and 
"Summary"  are  put  at  the  head  of  the  chart  merely  for  the  sake 
of  convenience,  so  that  at  any  time  in  referring  to  a  patient's  his- 


^21G  EQl'ILIBRIIM  AM)  VERTIGO 

toiy  we  have  the  name  and  iiinnediately  beh)\v  the  i)riiicipal  find- 
ings of  the  examination.     The  patient's  chief  complaint  is  first 

ClIAKT  I  A 

Name  A^p  Date 

Address 

Referred  by 

DIAGNOSIS: 


SUMMARY: 


Complains  of 


HISTORY: 

Dizziness 
Staggering 
Deafness 
Tinnitus 


NOSE: 


THROAT: 


A.  D. 
EARS: 

A.S. 


Fistula 


Hearing  Testa 

A| 

A 

Ac 

Be 

=  1 

Ac 

Be 

Pol.  I  c*  I  Gait  I 

I  I  I 


noted,  as  it  states  at  once  the  purpose  of  the  examination.  The 
history  of  the  case  is  then  taken,  paying  especial  attention  to  the 
following : 


ALDITORY  AND  VESTIBULAR  APPARATUS 


^217 


CHART  ]  B 

TESTS  OF  THE  VESTIBULAR  APPARATUS 

SPONTANEOUS 


NYSTAGMUS 

POINTING 

RIGHT 

LEFT 

Looking  to  RIGHT 

Shoulder  from  above 

Looking  to  LEFT 

Nystagmus 

Looking  UP 

Vertigo 
Past-pointing 

Looking  DOWN 

FaUing 

Romberg 

Turning  head  to  right 
Turning  head  to  left 
Attempt  to  overthrow 

TURNING 

To  RIGHT 

To  RIGHT 

Amp. 

Shoulder  from  above 

to 

to 

Duration         Sec. 

1 

Nystagmus 

Vertigo 

Past-pointing 

To  LEFT 

To  LEFT 

Amp. 

Shoulder  from  above 

to 

to 

Duration        Sec. 

Nystagmus 

Vertigo 

Past-pointing 

CALORIC 

Douche  RIGHT 

Douche  RIGHT 

Amp. 

Shoulder  from  above 

to 

to 

After        min.        lec. 

1 
Nystagmus 
Vertigo 
Past-pointing 
Falling 

Head  Back 

to 

to 

Amp. 

Douche  LEFT 

Douche  LEFT 

Amp. 

Shoulder  from  above 

to 

to 

After         min.        sec. 

Nystagmus 

Vertigo 

Past-pointing 

Falling 

Hetd  Back 

to 

to 

Amp. 

From  Dr.  L  H.  Jones'  Equilibrium  and  Vertigo. 


Copyright.  1918.  by  J.  B  Lippiocott  Co. 


.218  EQriLIBRIT'M  AND  VERTIGO 

(1)  Dizziness.  Tlie  jtatieiit  is  asked  at  what  time  in  his  life 
lie  first  noticed  the  dizziness.  If  the  dizziness  came  on  gradually 
or  suddenly?  Was  it  a  steadily  increasinj^  dizziness  over  several 
weeks  or  months  or  did  he  have  a  sudden  attack?  If  he  had  an 
attack,  did  it  come  on  with  a  sudden  change  of  position,  for  example 
wlien  he  got  out  of  bed  in  the  morning  or  when  washing  the  face! 
Was  there  nausea  and  vomiting.^  Does  lie  have  periodic  attacks 
of  this  sort? 

(2)  Staggering.  Does  the  staggering  come  on  suddenly  or 
gradually?  Is  it  constant  or  does  it  come  on  intermittently?  Was 
it  accompaiiieil  by  dizziness  or  did  it  follow  an  attack  of  dizziness? 
Was  the  staggering  sufficiently  severe  to  cause  him  to  fall  at  any 
time?  To  which  side  did  he  fall?  Did  the  staggering  take  place 
in  any  definite  direction?  In  walking  did  he  notice  whether  he 
tended  to  walk  toward  one  side?  If  staggering  or  falling  are 
present,  is  it  always  in  the  same  direction?  Has  the  feeling  of 
unsteadiness  increased  or  decreased? 

(3)  Deafness.  When  was  it  first  noticed?  Was  it  a  gradual 
impairment  or  a  sudden  loss  of  hearing?  Did  it  seem  to  come  as 
the  result  of  a  definite  cause,  such  as  a  loud  explosion,  a  fall  or  an 
illness  ? 

(4)  Tinnitus.  When  was  it  first  noticed  ?  What  kind  of  a  noise 
is  it  ?  Is  it  the  sound  of  bells,  the  rushing  of  a  railroad  train,  or  is 
it  a  sound  synchronous  with  a  heart-beat?  Are  the  subjective 
noises  increasing  or  decreasing? 

All  other  questions  as  to  the  history,  such  as  the  family  history 
or  previous  medical  history,  may  be  recorded  at  this  point.  When 
dealing  with  patients  of  suf!icient  intelligence,  it  is  a  great  con- 
venience to  ask  the  patient  to  write  his  own  history  at  home;  he 
is  instructed  to  write  down  in  his  own  way  all  that  he  can  remem- 
ber about  vertigo,  staggering,  deafness  and  noises  in  the  head. 
Having  this  done  at  home  not  only  saves  time  for  the  examiner,  but 
elicits  a  much  more  complete  history,  with  stress  perhaps  more 
correctly  ])laced  than  in  reply  to  leading  questions. 


AUDITORY  AND  VESTIBULAR  APPARATUS  219 

Nose  and  Throat 

The  routine  examination  of  the  nose  and  throat  is  then  made, 
in  order  to  determine  if  there  is  any  abnormality  which  may  have 
a  bearing  upon  the  condition  of  the  labyrinth  or  which  could  give 
information  of  an  intracranial  disturbance.  Such  conditions  would 
be  suppurative  sinus  disease,  anesthesia  of  the  nose  or  throat, 
paralysis  of  the  tongue,  paralysis  of  the  vocal  cords  or  absence  of 
taste  or  smell. 

The  Ear 

By  an  examination  of  the  external  and  middle  ear  we  note  the 
following : 

(1)  Configuration  of  the  auditory  canal. 

(2)  The  presence  or  absence  of  a  mechanical  obstruction  in 
the  canal,  congenital  or  acquired;  of  the  latter  there  may  be  im- 
pacted cerumen  or  other  debris  or  polypi. 

(3)  The  presence  of  inflammation  or  suppuration.  If  suppura- 
tion is  i3resent  the  fistula  test  is  made ;  this  can  be  done  with  the 
pneumatic  otoscope  or  the  Politzer  bag.  The  ear-piece  must  be 
closely  fitted  into  the  external  canal,  preventing  escape  of  air.  On 
pressing  the  rubber  bulb,  it  is  noted  whether  there  occurs  any 
nystagmus  or  vertigo.  These  phenomena  can  usually  be  elicited 
only  when  there  is  a  communication  between  the  external  world  and 
the  internal  ear  because  of  caries  of  the  outer  wall  of  the  laby- 
rinth ;  the  fistula  test  is  occasionally  positive,  however,  in  cases  in 
which  the  foot-plate  of  the  stapes  is  unduly  mobile  in  the  oval 
window. 

(4)  The  condition  of  the  tympanic  membrane.  The  length  of 
time  necessary  to  douche  before  a  reaction  appears  may  depend 
in  a  measure  upon  the  thickness  of  the  drumhead.  Perforations 
are  looked  for,  since  a  ''dry  perforation"  would  be  a  contraindica- 
tion to  douching. 


^2^20  I:QTU LIBRIUM  AND  VERTIGO 

Functional  Tests  of  Hearing 

We  are  now  in  a  position  to  test  the  hearing.  It  is  a  great 
privilege  to  present  here  for  the  first  time  in  book-form  the  sim- 
plified method  of  the  functional  tests  of  hearing  of  B.  A.  Randall, 
whose  teachings  may  safely  be  regarded  as  the  "last  word"  on  this 
subject.  These  tests  are  very  simple  and  briefly  recorded  on  two 
parallel  lines :  The  upper  line  represents  the  right  ear — the  lower 
line  the  left  ear.  A  glance  at  the  chart  will  show  that  all  the  im- 
portant tests  of  hearing  essential  to  a  diagnosis  are  made,  and 
yet  the  tests  can  be  made  in  a  very  few  minutes.  "A^"  represents 
the  tuning  fork  of  50  double  vibrations  per  second.  This  tuning 
fork  is  set  in  vibration  and  brought  toward  the  ear,  end  on ;  the 
distance  from  the  ear  at  which  the  patient  first  perceives  the  sound 
is  noted  alongside  of  this  letter.  The  "A"  not  underlined  repre- 
sents the  tuning  fork  of  200  double  vibrations.  To  impart  to  this 
fork  a  stroke  of  standard  strength,  it  is  placed  vertically  ui)on 
the  middle  of  the  thigh  and  the  tines  are  allowed  to  drop  of  their 
own  weight  against  the  muscular  cushion  of  the  knee;  it  is  then 
brought,  end  on,  toward  the  ear,  and  the  distance  at  which  it  is  first 
heard  is  noted.  C4  represents  a  tuning  fork  of  2000  double  vibra- 
tions. This  fork  is  not  used  for  distance,  but  it  is  noted  whether 
the  hearing  of  this  fork  is  good,  fair,  poor  or  none.  Ac  represents 
"air  conduction."  Be  represents  "bone  conduction."  N  repre- 
sents "normal."  For  this  test  the  A  fork  is  used  (of  200  vibra- 
tions) and  it  is  noted  whether  this  fork  is  heard  better  held  in 
front  of  the  ear,  or  when  the  stem  is  held  against  the  mastoid 
process;  the  patient  is  merely  asked  whether  it  is  louder  "front" 
or  "back."  If  the  sound  is  heard  better  in  front  of  the  ear  than 
when  pressed  against  the  bone,  this  is  represented  by  the  algebraic 
sign  "greater  than"  (  >  ),  and  is  recorded  as  Ac  >  Be.  The  tuning- 
fork  is  then  pressed  against  the  mastoid  process  and  the  patient 
is  asked  to  say  "gone"  at  the  moment  when  he  ceases  to  hear  it; 
he  should  hear  it  as  long  as  the  examiner  can  feel  the  vibrations 
of  the  fork  with  his  fingers.  If  the  patient  says  "gone"  at  the 
moment  that  the  examiner  ceases  to  feel  it  with  his  fingers,  the 


AUDITORY  AND  VESTIBULAR  APPARATUS  2^21 

result  is  recorded  as  Be  equal  to  N  (Bc^N).  If  he  says  "goue" 
before  the  vibrations  have  ceased,  it  is  recorded  by  the  algebraic 
sign,  less  than,  namely  Be  <  N.  If,  on  the  other  hand,  the  patient 
continues  to  hear  it  after  the  examiner  has  ceased  to  feel  it,  it  is 
recorded  Be  greater  than  N  (  Be  >  N).  Gait,  represents  the  Galton 
, whistle.  By  starting  at  the  topmost  portion  of  the  whistle,  the 
barrel  is  slowly  turned,  cautioning  the  patient  to  tell  the  examiner 
when  he  hears  not  only  the  puffing  sound,  but  also  the  distinct 
squeak.  The  number  is  read  on  the  barrel  and  recorded.  Pol.  rep- 
resents the  Politzer  test.  The  200  fork  is  set  in  vibration  and  held 
in  front  of  the  nostrils.  The  patient  is  asked  to  swallow.  If  on 
swallowing  he  hears  the  sound  louder,  it  indicates  a  normal  opening 
of  the  eustachean  tubes  in  the  act  of  swallowing.  This  is  recorded 
as  P0I.+.  The  Weber  test  is  the  last  used;  the  tuning  fork  is  set 
in  vibration  and  placed  on  the  vertex  of  the  head  or  in  some  other 
position  midway  between  the  two  ears,  and  the  patient  is  asked  in 
which  ear  he  hears  it  louder.  If  he  hears  it  louder  in  the  right 
ear,  a  capital  "W"  is  placed  on  the  upper  line;  if  he  hears  it 
louder  in  the  left  ear,  a  "  W"  is  placed  on  the  lower  line. 

In  these  two  lines  then  we  have  the  information  to  determine 
the  following:' 

(1)  The  approximately  lowermost  range  of  hearing,  the  median 
range  of  hearing,  and  the  highest  range  of  hearing. 

(2)  The  relation  of  air-conduction  to  bone-conduction. 
(o)   The  duration  of  bone  conduction. 

(4)  The  patulency  of  the  eustachean  tubes. 

(5)  The  lateralization  of  sound. 

In  other  words,  we  have  determined  all  the  essential  features 
necessary  to  make  a  diagnosis  of  the  auditory  apparatus  as  well 
as  determining,  if  any  deafness  exists,  whether  it  is  an  obstructive 
lesion  of  the  conducting  apparatus  of  the  ear  or  a  percipient  lesion 
of  the  internal  ear.  And  yet  the  entire  series  of  tests  consumes 
only  a  few  minutes,  and  the  only  instruments  used  are  three 
tuning  forks  and  a  Galton  whistle. 


•222  EQUILIBRIUM  AND  VERTIGO 

Examination  ok  tiik  A'estiiular  Apparatus. 

AVe  are  now  ready  for  the  vestibular  tests,  all  of  wiiieli  are  out- 
lined on  the  "vestibular"  side  of  the  chart. 

SpoNTANEors  Phenomena 
nystagm  us 

The  j)atient  is  instructed  to  look  straight  ahead  of  him  at  a 
distant  point.  It  is  then  noted  if  he  has  any  spontaneous  nystag- 
mus. The  effort  at  convergence  when  looking  at  a  near  object  will 
obscure  the  findings,  as  it  is  capable  of  limiting  or  entirely  elfacing 
a  nystagmus.  Opaque  spectacles  may  be  used,  and  the  eyes  ob 
served  behind  them  by  looking  at  the  eyes  from  above.  Bartels 
first  suggested  the  use  in  this  connection  of  convex  lenses.  Tliese 
hiwc  a  double  advantage;  in  the  first  place,  the  observer  is  alile  to 
view  the  eyes  from  in  front;  in  the  second  ])lace,  the  eyes  are 
greatly  magnified  and  any  slight  nystagmus  is  more  easily  ob- 
served. These  convex  lenses  are  so  powerful  that  they  prevent 
accommodation  and  convergence  and  thus  accomplish  the  same 
results  as  looking  at  a  distance. 

The  patient  is  now  told  to  look  to  the  right,  to  look  to  the  left, 
up  and  down.  This  may  be  accomplished  without  help  from  the 
observer,  j^rovided  the  patient  is  intelligent.  It  is  also  helpful, 
however,  for  the  examiner  to  hold  his  finger  at  a  distance  of  two 
feet  away  from  the  eyes  of  the  patient  and  to  move  the  finger  to 
the  rigiit,  to  the  left,  up  and  down,  and  have  the  patient  follow  the 
direction  of  his  finger.  Another  simple  method  for  examining  for 
spontaneous  nystagmus  is  to  place  the  patient  in  the  revolving- 
chair,  have  him  fix  his  eyes  on  some  distant  point  and  then  turn 
the  chair  first  to  the  right  and  then  to  the  left.  In  this  way  we 
revolve  the  body,  as  it  were,  around  the  eyes;  this  is  very  useful 
m  stupid  individuals  or  in  patients  who  are  Aveak  or  irritable. 
All  the  patient  is  required  to  do  is  to  keep  looking  at  some  par- 
ticular object.  By  any  of  these  methods  it  is  observed  whether  any 
nystagmus  occurs  when  the  eyes  are  looking  to  the  extreme  right 
or  the  extreme  left.     The  patient  is  then  told  to  look  up  at  the 


AUDITORY  AND  VESTIBULAR  APPARATUS  2€S 

ceiling  and  down  at  the  floor  and  it  is  noted  if  any  nystagmus 
occurs  in  these  extreme  positions  of  the  eyes.  At  tlie  same  time, 
also,  when  the  patient  is  looking-  in  different  directions,  we  observe 
any  })aralysis  or  paresis  of  the  eye  muscles.  If  there  be  any  limi- 
tation of  movement  of  the  eye  or  eyes,  it  is  of  course  best  when 
possible  to  have  the  patient  examined  by  an  ophthalmologist ;  but 
it  is  necessary  for  the  otologist  to  familiarize  himself  with  the 
spontaneous  action  of  the  eyes  in  any  given  case  before  he  under- 
takes the  vestibular  tests. 

In  examining  the  eye  for  nystagmus,  it  is  essential  to  have  a 
good  illumination.  Occasionally,  it  is  helpful  to  use  reflected  light 
from  a  head  mirror.  In  order  to  have  a  good  view  of  the  eye-ball, 
the  upper  lid  may  be  raised  l\v  the  thumb  of  the  examiner.  In 
examining  for  a  horizontal  nystagmus,  the  patient  is  directed  to 
look  straight  ahead;  the  examiner  can  note  the  most  minute 
twitches  by  observing  the  inner  margin  of  the  cornea,  at  which 
point  there  is  a  glistening  light-spot  where  the  cornea  curves  into 
the  surface  of  the  sclera.  In  examining  for  a  rotary  nystagnnis, 
it  is  often  helpful  to  have  the  patient  look  occasionally  at  the  floor ; 
this  reveals  the  upper  part  of  the  sclera  and  the  little  vessels  radi- 
ating in  the  sclera  will  then  show  the  slightest  rotary  movement. 
Under  all  circumstances  the  examiner  nmst  remember  to  close  tlie 
eye  occasionally  by  jDushing  the  upper  lid  down  Avith  his  thumb 
and  then  lifting  it  up  again;  otherwise  the  drying  of  the  conjunc- 
tiva which  occurs  very  quickly  is  unpleasant  to  the  patient. 

Nystagmus  is  recorded  by  means  of  an  arrow — a  straight  one 
for  horizontal  nystagmus  and  a  curved  one  for  rotarj^  nystagnms. 
It  seems  simpler,  as  suggested  by  George  Mackenzie,  to  have  the 
arrow  point  in  the  direction  in  which  the  examiner  sees  the  nys- 
tagmus on  the  patient. 

Spontaneous  Veetigo 

The  patient  is  asked  not  merely  whether  he  is  ''dizzy,"  but 
whether  he  has  any  sensation  of  turning.  If  the  latter  is  present 
he  is  asked  to  note  carefully  wdiether  the  turning  is  systematized 
or  not.    By  systematized  vertigo  is  meant,  (1)  Does  he  feel  he  is 


^2^24  KQllUHRirM  AM)  VERTKiO 

going  ill  a  definite  direction?  (2)  Does  lie  feel  that  he  is  not  mov- 
ing but  the  outside  world  is  going  in  one  direction  around  him? 
(3)  Does  he  feel  that  lie  h  going  in  one  direction  and  the  outside 
world  is  going  in  another  direction  ? 


SPONTANEOUS    POINTING 

The  object  of  the  test  is  explained  to  the  patient,  namely,  that 
with  closed  eyes  he  is  to  feel  the  finger,  raise  his  arm  to  the  vertical 
position  and  come  back  and  try  his  best  to  fiind  the  finger  again. 
It  is  im])ortant  not  to  have  him  move  the  arm  too  fast.  From  the 
instant  that  he  leaves  the  finger  until  he  comes  back  to  it  again  the 
movement  should  occupy  about  two  seconds.  The  results  are 
recorded  under  the  pointing  column.  Pointing  of  the  right  arm  is 
recorded  under  the  word  "right"  and  the  pointing  of  the  left 
arm  under  the  word  ''left,"  If  the  patient's  arm  deviates  either 
to  the  right  or  to  the  left,  the  test  is  repeated  a  number  of  times 
to  make  sure  that  the  failure  is  not  the  result  merely  of  pure  inat- 
tention, but  that  the  deviation  is  constant  and  persistent  in  a  cer- 
tain direction.  The  distance  of  the  deviation  is  recorded  in  inches 
either  to  the  right  or  to  the  left  as  the  case  may  be,  by  noting  under 
the  appropriate  column — let  us  say  "2  to  E.,"  if  the  deviation 
happens  to  l)e  two  inches  to  the  right,  or  ''2  to  L.,"  if  the  deviation 
]ia})pens  to  be  to  the  left,  etc.  If  the  patient  fails  to  find  the  finger 
and  past-points  either  to  the  right  or  to  the  left,  his  arm  must 
never  be  pulled  over  towards  the  examiner's  finger,  if  the  test  is 
to  be  repeated,  because  if  this  is  done  the  jiatient  finds  out  that  lie 
has  "past-pointed"  and  might  then  make  a  conscious  correction  to 
overcome  his  actual  tendency  to  past-point.  Instead  the  examiner 
should  again  place  his  own  finger  under  that  of  the  patient.  In 
taking  the  pointing,  it  is  usually  sufficient  to  test  the  pointing  only 
of  the  "shoulder  from  above,"  as  described;  the  other  forms  of 
pointing,  such  as  "shoulder  from  below"  or  "shoulder  from  the 
side"  are  not  performed  routinely — these  are  undertaken  only  in 
cases  where  such  extensive  examinations  appear  to  be  necessary. 


AUDITORY  AND  VESTIBULAR  APPARATUS  225 

SPONTANEOUS    FALLING 

The  Romberg  test.  The  patient  is  told  to  stand  with  the  heels 
and  toes  close  together  and  close  his  eyes.  Any  swaying  or  falling 
is  noted,  particularly  the  direction  of  the  falling,  if  any  is  present. 
The  Romberg  test  is  merely  a  refined  method  of  testing  for  spon- 
taneous falling. 

Turning  head  to  right  and  turning  head  to  left.  This  is  done 
at  the  same  time  after  taking  the  Romberg  test ;  the  patient  is 
asked  to  turn  his  head  sharply  to  the  right  and  then  to  the  left 
and  the  examiner  observes  whether  the  direction  of  falling  is 
changed  or  whether  the  amount  of  swaying  is  increased,  with 
the  head  in  these  different  positions.  ^ 

The  "attempt  to  overthrow"  is  Barany's  pelvic  girdle  test. 

Figures  85,  86,  87  and  88  show  the  pelvic  girdle  test.  The 
patient  stands  as  before  with  the  heels  close  together;  the  exam- 
iner grasps  the  shoulders  of  the  patient  and  attempts  to  over- 
throw him  either  to  one  side  or  the  other,  forward  or  backward. 
The  patient  is  told  to  balance  himself  so  that  he  will  not  fall. 
When  the  shoulders  of  the  patient  are  pressed  toward  the  right, 
the  pelvis  should  sway  toward  the  left  in  the  attempt  to  maintain 
equilibrium.  In  this  way  the  flexibility  and  degree  of  freedom 
of  the  pelvic  movement  is  observed. 

The  goniometer  is  a  platform  on  which  the  patient  is  placed. 
This  platform  is  so  arranged  that  it  can  be  tilted  gradually  out 
of  the  horizontal  plane.  It  is  a  refined  method  of  testing  the 
tendency  to  fall  in  a  given  direction.  The  pictures  show  the 
method  of  using  the  goniometer.  The  goniometer  shown  in  the 
pictures  was  made  by  S.  A.  Brumm.  Fig.  89  shows  the  patient 
facing  the  examiner,  and  standing  on  a  board  supported  in  the 
centre  by  braces  and  at  one  end  by  an  upright  board.  The  plat- 
form on  which  he  stands  is  supported  at  these  two  points.  At 
the  other  end  a  rope  is  attached  which  runs  through  a  pulley  im- 
mediately beneath.  When  the  examiner  pulls  on  this  rope,  as  is 
shown  in  the  picture,  the  platform  is  tilted.  At  the  other  end 
of  the  platform  there  is  a  strong  spring,  which  pulls  the  platform 

1.5 


Fio.   bo. — Baiany's  pelvic  girdle  test. 


Fig.  86. — Barany's  pelvic  girdle  test. 


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FiQ.  87. — Barany's  pelvic  girdle  test. 


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Fig.  88. — Barany's  pelvic  girdle  test. 


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BaK*5 


Fig.   89. — Goniometer. 


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Fig.   90. — Goniometer. 


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Fig.   91. — Goniometer. 


AUDITORY  AND  VESTIBULAR  APPARATUS  233 

back  into  the  horizontal  plane,  where  it  again  rests  on  a  support 
attached  to  the  upright  board.  This  upright  board  is  marked  off 
according  to  a  graduated  scale,  which  shows  the  exact  number 
of  degrees  of  the  inclination  of  the  platform ;  this  can  be  read  otf 
by  the  examiner  at  the  moment  that  the  patient  is  unable  to  main- 
tain his  equilibrium.  In  Fig.  89  the  patient  is  standing  in  the 
centre  of  the  platform  facing  the  examiner,  who  is  holding  the 
rope.  The  patient's  eyes  are  open.  The  examiner  gradually  pulls 
on  the  rope  until  he  notices  that  the  patient  is  beginning  to  sway, 
whereupon  he  gradually  loosens  the  rope  and  allows  the  platform 
to  go  back  to  the  horizontal  position.  Fig.  90  shows  the  patient 
facing  a^vay  from  the  examiner.  The  tests  with  the  patient  facing 
the  examiner  or  turned  directly  away  from  the  examiner  bring 
out  a  latent  tendency  to  fall  either  forward  or  backward.  Fig. 
91  shows  the  patient  standing  sideways  on  the  platform.  These 
tests  would  bring  out  a  lateral  falling.  The  more  delicate  test 
naturally  is  with  the  eyes  closed,  as  the  patient  is  then  dependent 
entirely  on  the  semicircular  canals  and  muscle-sense.  By  means 
of  the  goniometer  it  is  sometimes  possible  to  bring  out  a  latent 
tendency  to  fall,  not  demonstrable  in  any  other  way.  This,  how- 
ever, is  only  occasionally  useful,  and  the  gonimeter  need  not  be 
used  routinely. 

Turning 

In  order  to  carry  out  the  turning-test  with  any  degree  of  accu- 
racy, it  is  essential  to  have  a  revolving-chair  especially  constructed 
for  this  purpose.  Not  only  must  it  revolve  smoothly,  but  it  must 
have  the  necessary  attachments  for  holding  the  head  in  the  proper 
position  as  well  as  a  stopping  device  to  clamp  it  instantly  and 
firmly.  Barany  has  constructed  a  chair  for  this  purpose.  He  sent 
us  one  of  these  chairs  (Fig.  92)  which  we  were  fortunate  enough  to 
receive  only  a  few^  days  before  the  outbreak  of  the  war  in  Europe. 
So  far  as  we  know  it  is  the  only  one  in  this  country.  As  it  was 
hardly  probable  that  any  more  chairs  of  this  kind  could  come  out 
of  Vienna  for  some  time,  we  were  asked  to  design  a  chair  along 


234 


EQUILIBRIUM  AND  VERTIGO 


Fig.  92. — Original  Barany  chair. 


AUDITORY  AND  VESTIBULAR  APPARATUS  235 


Fig.  93. — Latest  •modification  of  American  Barany  chair. 


236  EQUILIBRIUM  AND  VERTIGO 

similar  lines.  After  the  Barany  chair  had  been  used  for  a  few- 
months,  the  following  changes  suggested  themselves  and  were  in- 
corporated in  the  new  chair  (Fig.  93)  : 

(1)  The  back  of  the  chair  and  the  head-rest  are  so  constructed 
that  the  patient's  head  is  placed  immediately  over  the  axis  of 
turning.  This  is  obviously  of  great  importance.  In  the  original 
Barany  chair  the  head  revolves  away  from  the  centre  of  turning 
and  describes  a  circle  with  a  diameter  of  over  a  foot. 

(2)  It  is  impossible  in  the  Barany  chair  to  hold  the  head  in  a 
forward  position;  we  therefore  constructed  an  extra  headpiece 
to  permit  rotation  wdth  the  head  inclined  forward.  It  is  obvious 
that  it  is  absolutely  essential  for  the  head  to  be  held  steady  when 
being  rotated  in  this  jjosition,  and  this  cannot  be  accomplished 
without  a  special  head-bracket. 

(3)  Instead  of  having  a  special  handle  for  turning,  as  in  the 
Barany  chair,  the  rod  at  the  back  of  the  chair  is  made  slightly 
longer  and  a  handle  placed  at  the  top.  The  extra  handle  was  very 
annoying  and  interfered  with  the  pointing  tests  of  the  right  arm 
by  its  presence  on  the  side  of  the  chair. 

(4)  The  base  is  much  heavier  than  in  the  Barany  chair,  in 
order  that  the  patient  may  be  rotated  rapidly,  if  necessary,  and 
yet  not  have  the  chair  wobble ;  this  gives  both  the  patient  and  the 
examiner  a  greater  sense  of  security. 

(5)  The  Barany  chair  is  bound  together  by  a  great  many  bolts. 
In  order  to  take  the  chair  apart,  in  case  it  is  desired  to  move  it,  all 
these  bolts  must  be  undone.  In  the  new  chair  there  are  no  bolts 
and  the  parts  are  all  welded ;  the  chair  consists  of  only  two  pieces 
— the  seat  and  the  base.  This  makes  it  more  portable,  and  is  a 
great  convenience  when  a  patient  has  to  be  examined  at  a  place 
wdiere  no  such  chair  can  be  had.  In  constructing  this  chair  we 
also  aimed  to  make  it  suitable  for  use  as  a  regular  office  treatment 
and  operating  chair,  so  tliat  it  w^ould  not  require  any  extra  room 
in  tlie  office. 

Nystagmus  After  Turning 

The  patient  is  seated  in  the  chair  with  the  head  inclined  for- 
ward 30°,  wdiich  puts  the  horizontal  canals  in  the  horizontal  plane 


AUDITORY  AND  VESTIBULAR  APPARATUS  237 

(Fig,  94).  Eyes  closed.  The  chair  is  then  rotated  to  the  right  ten 
times,  at  a  speed  of  two  seconds  to  each  turn,  making  twenty  sec- 
onds for  the  ten  turns,  after  which  it  is  stopped.  The  patient  keeps 
his  eyes  closed  during  the  turning  and  is  told  to  open  his  eyes 
again  when  the  chair  is  stopped.  The  after-turning  nystagmus  is 
then  noted,  including  its  direction,  character  and  duration.  It  is 
necessary  to  time  the  duration  of  the  nystagmus  with  a  stop-watch. 
At  the  instant  the  chair  stops,  start  the  stop-watch.  After  the  last 
twitching  of  the  eyes  has  ceased,  the  stop-watch  is  again  clicked 
and  the  time  noted.  The  patient  is  first  turned  to  the  right.  After 
the  observation  of  the  nystagmus,  it  is  best  to  wait  a  minute,  until 
not  only  the  nystagmus  has  stopped,  but  also  the  subjective  sen- 
sations have  ceased.  The  patient  is  turned  to  the  left  in  a  similar 
manner  and  the  nystagmus  noted.  Turning  in  this  position  with 
the  head  30°  forward  has  tested  the  horizontal  canals. 

To  test  the  vertical  canals  by  turning,  the  head  is  put  forward 
120°  (Fig.  95).  As  a  matter  of  fact  this  forward  bend  of  the  head 
is  somewhat  difficult  at  such  a  marked  angle.  For  all  practical 
purposes  the  forward  position  of  the  head  at  90°  answers  for  the 
stimulation  of  the  vertical  canals.  After  turning  the  patient  ten 
times  and  then  stojDping  the  chair,  we  examine  the  nystagmus 
either  by  stooping  down  low  enough  to  see  the  eyes  of  the  patient 
or  by  lifting  the  patient's  head  from  the  forward  head-rest  to 
the  back  head-rest.  Changing  the  position  of  the  head  after  turn- 
ing does  not  alter  the  direction  of  the  nystagmus.  Another  method 
of  examination  for  the  vertical  canals  is  to  turn  with  the  head 
tilted  backward  60°  (Fig.  96),  which  produces  a  nystagmus  in 
exactly  the  opposite  direction  to  that  produced  with  the  head  for- 
ward. If  we  desire  to  produce  a  vertical  nystagmus,  the  patient's 
head  is  inclined  toward  his  shoulder  and  held  in  that  position  by 
the  movable  head-rest.  After  stopping  the  chair  the  nystagmus 
can  be  examined  with  the  head  maintained  in  this  position,  or 
brought  upright.  The  type  of  nystagmus  is  recorded  in  the  nystag- 
mus column,  the  number  of  seconds  noted,  and  the  amplitude 
recorded  in  terms  of  either  "Large,"  "Small,"  "Fair,"  or 
"Barely  a  twitch." 


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t^ 


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Fig.  94. — Turning  to  the  right,  head  .30°  forward,  stimulating  both  liorizontal  canals. 


O   V 


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m 


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Fig.  95. — Turning  to  right,  head  120°  forward,  stimulating  vertical  canals  of  both  ears. 


i'lirfl-. 


Fig.  96 — Turning  to  the  right,  head  C>1°  hack,  stinaulating  the  vertical  canals  of  both  ears. 


AUDITORY  AND  VESTIBULAR  APPARATUS  241 

Vertigo  After  Turning 

As  a  rule  it  is  not  necessary  to  turn  the  patient  all  over  again 
merely  for  this  test.  Tlie  i)ast-pointing,  when  it  is  tested  routinely, 
of  itself  gives  us  the  evidence  of  the  subjective  vertigo.  If  a  more 
accurate  determination  is  desirable,  however,  the  vertigo  after 
turning  ma}^  be  tested  quantitatively.  The  patient,  with  eyes  closed, 
is  turned  to  the  right  at  a  speed  of  one  second  to  each  turn  and  is 
asked  to  keep  on  telling  the  examiner  in  which  direction  he  is  being 
turned.  Thus  he  keeps  on  saying  "To  the  right — to  the  right." 
After  ten  turns  in  ten  seconds  the  chair  is  stopped  and  imme- 
diately he  will  say  "I  am  going  to  the  left — to  the  left."  The 
stop-watch  is  started  at  this  instant  and  kept  running  as  long  as 
the  patient  thinks  he  is  going  to  the  left.  When  he  says  "I  am 
standing  still,"  the  watch  is  stopped  and  the  reading  of  the  dura- 
tion of  the  vertigo  taken  in  seconds.  This  is  the  method  for  the 
quantitative  estimation  of  vertigo  after  turning. 

Past-pointing  After  Turning 

The  patient  is  turned  to  the  right  at  a  speed  of  one  turn  to  the 
second.  That  is  to  say,  ten  turns  in  ten  seconds.  During  the 
tenth  revolution  of  the  chair,  the  foot-p*edal  is  released  simply  by 
touching  it  with  the  foot.  The  chair  when  it  reaches  the  original 
front  position  is  then  clamped  rigidly.  Naturally  the  patient  must 
not  receive  a  jolt  as  the  chair  is  clamped.  Therefore  during  the 
last  half  of  the  final  turn  the  examiner  first  releases  the  foot-pedal 
and  then  grasps  the  chair  and  gradually  stops  it,  allowing  the 
clamp  to  fasten  on  it  gently.  The  right  index  finger  is  then  seized 
by  the  examiner's  left  hand  and  placed  on  the  examiner's  right 
forefinger.  The  patient's  finger  is  placed  firmly  against  the  finger 
of  the  doctor.  Once  the  fingers  are  approximated,  the  doctor 
says  "up,"  the  patient  then  raises  his  arm  to  tlie  perpendicular 
and  immediately  comes  down  again,  trying  to  find  the  finger.  The 
left  forefinger  is  then  immediately  seized  by  the  examiner  and 
the  left  arm  tested  in  a  similar  way.    The  right  arm  is  then  again 

16 


242  EQUILIBRIUM  AND  VERTIGO 

tested.  The  left  arm  is  tested.  This  testing  of  one  arm  after 
the  other  is  continued  until  all  past-pointing  ceases.  In  this  way 
we  test  the  duration  of  the  past-pointing  stimulus.  In  other  words 
we  not  only  determine  the  extent  of  the  past-pointing  of  each  arm, 
but  also  how  long  the  past-pointing  continues  before  the  patient 
is  again  able  to  find  the  finger  of  the  doctor.  The  extent  of  the 
past-pointing  of  each  arm  is  recorded  in  inches  on  the  chart. 

It  is  sometimes  helpful  when  seizing  the  patient's  finger  to 
rub  one's  finger  back  and  forth  quickly;  this  impresses  the  patient 
with  the  exact  position  of  the  finger  and  can  easily  be  done  in  a 
second  of  time. 

In  cases  in  which  there  is  a  short-lived  stimulus,  as  in  lesions 
of  the  labyrinth  or  VIII  Nei-^^e,  there  is  frequently  an  immediate 
wide  past-pointing  of  the  right  arm,  but  the  left  arm,  tested  im- 
mediately afterwards,  touches  and  shows  no  past-pointing.  In 
such  a  case,  before  suspecting  that  there  is  an  absence  of  past- 
pointing  of  the  left  arm,  it  is  necessary  to  turn  all  over  again 
and  then  test  the  left  arm  first.  If  the  left  arm  past-points  prop- 
erly, then  the  right  arm  is  tested  again,  when  it  will  be  found 
that  the  right  arm  fails  to  past-point.  This  naturally  shows  that 
the  failure  of  past-pointing  is  because  the  stimulus  died  out  quickly 
and  not  that  there  was  a  disturbance  of  the  past-pointing  itself. 

As  a  rule  it  is  sufficient  to  test  only  the  "shoulder  from  above." 
If,  however,  we  wish  to  test  the  other  joints,  the  technic  is  the 
same.  For  instance,  after  turning  and  clamping  the  chair,  the 
foot  is  seized  and  the  big  toe  is  brought  up  in  contact  with  the 
finger  of  the  examiner,  the  patient  then  lowers  the  foot  and  imme- 
diately brings  it  up  again  in  the  attempt  to  find  the  finger. 

In  testing  for  the  past-pointing  of  the  arms,  it  is  advisable  not 
to  bring  the  patient's  arm  back  to  the  median  line  after  he  has 
once  past-pointed.  It  is  better  for  the  examiner  to  place  his  finger 
beneath  the  past-pointing  finger  of  the  patient,  and  again  testing, 
see  if  there  is  still  further  past-pointing.  The  obvious  reason  for 
this  is  that  pulling  the  arm  back  again  to  the  median  line  informs 
the  patient  that  he  has  past-pointed  and  may  modify  his  further 
attempts  to  find  the  finger. 


AUDITORY  AND  VESTIBULAR  APPARATUS  243 

It  is  usually  sufficient  to  record  the  amount  of  past-pointing 
by  the  examiner's  judgment  of  the  distance  in  inches  as  he  sees  it. 
It  is  sometimes  however  of  importance  to  note  the  exact  degree 
of  past-pointing.  For  this  purpose  we  use  the  Victor  Horseley 
screen,  modified  by  Mills.  The  screen  is  divided  off  into  one-half 
inch  squares.  It  is  placed  in  a  horizontal  position  immediately 
beneath  the  finger  of  the  examiner.  The  patient  touches  the  doc- 
tor's finger  as  usual,  raises  it  and  brings  it  down  right  on  the 
screen.  The  number  of  squares  is  then  counted  between  the  finger 
of  the  examiner  and  the  finger  of  the  patient.  This  gives  an  exact 
measure  in  inches  of  the  amount  of  past-pointing. 

On  stopping  the  chair  after  turning,  it  frequently  happens 
that  the  patient  will  lean  to  one  side  or  at  least  change  the  posi- 
tion of  his  head.  It  is  advisable  in  this  instance  for  an  assistant 
to  take  hold  of  the  head  and  hold  it  in  the  proper  position  in  the 
head-bracket  before  taking  the  pointing-tests.  Of  course  this  is  all 
done  in  a  moment's  time,  so  that  the  pointing-tests  may  be  taken 
practically  at  once  after  the  cessation  of  turning. 

It  must  be  remembered,  of  course,  that  the  eyes  are  kept  shut 
throughout  this  entire  test.  It  is  sometimes  difficult  for  a  patient 
to  remember  not  to  open  the  eyes.  Of  course  he  may  be  blind- 
folded, but  it  is  generally  sufficient  to  tell  him  "do  not  open  your 
eyes  the  rest  of  the  afternoon  until  you  are  told  to."  It  is  usually 
possible  to  obtain  a  sufficient  past-pointing  of  both  arms  on  one 
turning,  but  if  a  comparison  between  the  two  arms  is  advisable 
it  is  best  to  make  a  complete  ten  turns  for  the  right  arm  alone, 
then  to  turn  him  all  over  again  for  the  pointing  of  the  left  arm. 

Falling  After  Turning 

In  order  to  produce  falling  it  is  of  course  first  necessary  to 
produce  a  subjective  sensation  of  movement  in  one  of  the  vertical 
planes.  This  is  produced  by  stimulation  of  the  vertical  canals, 
either  (1)  with  the  head  forward  or  backward,  which  produces 
vertigo  in  a  frontal  plane,  or  (2)  with  head  inclined  90°  toward  the 
shoulder,  wliich  produces  vertigo  in  a  sagittal  plane.     The  usual 


244  EQUILIBRIUM  AND  VERTIGO 

method  is  with  the  head  forward.  The  patient  is  turned  to  the 
right  and  after  ten  turns  the  chair  is  stopped.  The  head  is  then 
raised  to  the  vertical  position  and  it  is  noted  in  whicli  direction 
the  patient  falls. 

If  no  falling  is  produced  we  can  make  further  tests :  Supposing 
that  there  is  a  lesion  of  the  VIII  Nerve  or  labyrinth  so  that  the 
turning  produces  very  little  effect.  Under  these  circumstances, 
we  M'ant  to  bring  out  to  the  fullest  extent  any  latent  tendency  to 
fall.  This  may  be  done  by  turning  the  patient  with  the  head  for- 
ward and  then  on  stopping,  the  patient  is  told  to  get  right  out  of 
the  chair  and  do  the  Romberg  test.  This  will  bring  out  even  the 
slightest  tendency  to  fall. 

Caloric  Test 

The  main  advantage  of  the  caloric  test  of  Barany  is  that  it 
enables  us  to  examine  each  internal  ear  separately  and  also  to 
analyze  the  function  of  its  canals  separately,  whereas  turning 
stimulates  both  labyrinths  at  the  same  time. 

Temperature  of  water.  It  is  essential  to  have  an  absolute 
standard.  As  Barany  directs,  we  employ  water  at  68°  F.  in  every 
case — not  a  degree  below  nor  a  degree  above.  This  temperature 
is  sufficiently  cool  to  secure  a  good  reaction,  and  yet  is  not  so  cold 
as  to  be  uncomfortable  to  the  patient.  It  is  rarely  advisable  to 
use  hot  water ;  it  is  much  more  uncomfortable  for  the  patient  and 
does  not  give  so  good  a  reaction  as  the  cold.  We  use  tempera- 
ture 112°  F. 

The  vessel  containing  the  water  is  placed  at  a  position  two  feet, 
a])i)roximately,  above  the  level  of  the  ear  to  be  douched.  The 
height  of  the  vessel  is  of  no  importance  whatever — the  only  mat- 
ter of  real  importance  is  that  the  stream  shall  not  be  so  powerful 
against  the  druiti  iii('nil)raii('  as  to  Ix'  uncomfortable  or  injurious. 
It  is  only  essential  that  a  continuous  stream  of  Avater  shall  flow 
against  the  drum  membrane  maintaining  an  even  temperature. 
The  shape  or  size  of  the  nozzle  is  immaterial.  Any  nozzle  that  will 
extend  a  short  distance  into  the  auditory  canal  is  satisfactory. 


AUDITORY  AND  VESTIBULAR  APPARATUS  245 

For  little  children,  for  example,  we  attach  the  nozzle  of  the  ordi- 
nary ear  syringe  used  for  removing  impacted  cerumen.  It  is  con- 
venient to  have  a  cut-off  arrangement  in  the  nozzle  itself,  although 
this  can  be  reg-ulated  nicely  merely  by  squeezing  the  rubber  tubing 
between  the  fingers. 

The  amount  of  water  is  of  no  importance  whatever,  as  it  is  not 
the  force  or  volume  of  water  that  produces  the  reactions,  but 
merely  the  maintaining  of  a  uniform  coldness  in  the  ear. 

The  patient's  head  is  placed  in  the  upright  position  (with  the 
head  tilted  forward  30°),  just  as  for  turning.  This  puts  the  verti- 
cal canals  in  the  vertical  position.  The  chair  is  held  firmly  by  the 
foot  clamp.  Stop-watch  ready.  The  nozzle  is  inserted  into  the 
canal  and  at  the  instant  at  which  douching  is  started,  the  stop- 
watch is  clicked.  It  is  possible  for  the  examiner  to  conduct  the 
examination  entirely  alone.  On  starting  the  douching,  he  clicks 
the  stop-watch  and  puts  it  in  his  pocket,  holding  the  nozzle  in  the 
ear  with  one  hand,  and  elevating  the  eye-lid  with  the  other  hand. 
In  this  way  he  watches  for  the  nystagmus  to  appear.  When  satis- 
fied that  a  rhythmic  nystagmus  has  started,  he  clicks  the  stop- 
watch, which  he  still  leaves  in  his  pocket  to  be  examined  later, 
and  then,  laying  aside  the  douching  nozzle,  he  tells  the  patient 
to  close  his  eyes,  and  then  undertakes  the  pointing  tests.  It  is  far 
better,  however,  to  have  a  trained  assistant  in  order  to  do  the  most 
careful  work;  for  example,  it  is  best  for  the  examiner  to  confine 
all  his  attention  to  the  douching,  in  order  to  make  sure  that  there 
is  a  continuous  flow  of  water  against  the  drum-membrane.  The 
assistant  takes  care  of  the  stop-watch  and  watches  the  eyes  for 
nystagmus. 

On  the  instant  that  it  can  be  said  that  there  is  a  definite  rhythmic 
nystagTiius,  no  matter  how  slight  in  amplitude,  the  stop-watch  is 
clicked  and  the  exact  time  noted.  It  is  our  custom  to  continue  the 
douching  for  a  few  seconds  longer  in  order  to  obtain  a  good  reac- 
tion. In  perhaps  five  or  ten  seconds  in  the  normal,  from  the  onset 
of  the  nystagmus,  the  amplitude  becomes  large.  The  direction  of 
the  nystagmus,  its  amplitude  and  rapidity  are  then  noted. 

The  patient  is  then  told  to  close  his  eyes  and  the  pointing  tests 


•240  EQUILIBRIUM  AND  VERTIGO 

are  carried  out.  First  the  right  arm,  shoulder  from  above,  then 
the  left  arm,  shoulder  from  above,  are  tested.  If  advisable,  the 
other  extremities  or  the  neck  and  trunk  may  be  tested.  The  dura- 
tion of  the  average  stinmlus  after  douching  is  long  enough  to  per- 
mit of  the  examination  of  several  jjarts  without  repeating  the 
douching.  In  this  connection  it  must  be  remembered  that  by 
douching  with  the  head  upright  we  have  produced  a  rotary  nys- 
tagmus in  the  frontal  plane,  and  that  there  is  also  a  marked 
tendency  for  the  patient  to  fall.  It  is  therefore  often  advisable 
for  an  assistant  to  hold  the  head  of  the  patient  firmly  in  the  head- 
rest before  taking  the  pointing  tests. 

Douching  with  the  head  backward  60°.  Bruenning  recommends 
that  the  head  not  only  be  placed  backward,  but  then  tilted  towards 
the  shoulder  of  the  side  douched.  This  is  not  essential  l)ut  produces 
a  quicker  reaction,  because  there  is  the  anatomical  position  for  the 
greatest  drop  of  the  enclolymph.  As  a  rule,  it  is  not  necessary  to 
perform  the  douching  test  all  over  again  simply  to  determine  the 
function  of  the  horizontal  canal.  The  ear  is  douched  with  the  head 
30'  forward,  and  as  soon  as  the  nystagmus  and  past-pointing  have 
been- noted,  the  head  is  quickly  tilted  to  a  position  60°  back,  which 
places  the  horizontal  canal  in  the  position  in  which  it  is  aifected  by 
the  chilling.  The  patient  is  told  to  look  upward  and  the  existing 
rotary  nystagmus  immediately  becomes  horizontal.  The  pointing 
of  both  arms  is  then  ciuickly  taken  with  the  head  in  that  position. 
The  head  may  then  be  tilted  forward  120°  and  the  past-pointing 
of  both  arms  be  taken  again.  This  new  position  of  the  head  again 
influences  the  horizontal  canal,  but  has  revei'sed  the  direction  of 
the  endolymph  movement.  All  the  responses,  therefore,  are  also 
reversed. 

The  caloric  test,  by  its  very  nature,  produces  vertigo  only  in  a 
plane  at  right  angles  to  the  floor,  so  that  "falling"  always  occurs 
on  douching  a  normal  ear.  All  that  is  routinely  necessary  is  to  ob- 
serve the  tendency  to  fall,  while  the  other  examinations  are  going 
on,  or,  after  completing  the  tests  with  the  head  in  different  posi- 
tions, to  have  the  patient  stand  and  do  the  Romberg  test. 

Of  course,  before  douching  the  ear,  it  is  absolutely  necessary 


AUDITORY  AND  VESIIBULAR  APPARATUS  247 

to  make  a  careful  examination  of  the  drum-membrane  and  canal. 
In  the  case  of  a  healed  otitis  media  with  a  permanent  perforation, 
it  is  obviously  unwise  to  douche  at  all,  as  there  is  a  grave  likeli- 
hood of  lighting  up  the  old  trouble.  In  such  a  case  we  can  either 
rely  entirely  upon  the  turning  or  we  can  use  the  galvanic  test; 
if,  however,  the  caloric  test  would  be  of  unusual  importance,  there 
may  be  used  an  apparatus  which  would  introduce  cold  air  against 
the  drum-head.  Various  types  of  apparatus  for  this  purpose 
have  been  devised  by  Ruttin,  Bloch,  Dundas  Grant  and  Aspisoff. 
Cold  air  is,  however,  rather  unsatisfactory.  Then,  again,  if  we 
are  making  the  pointing  tests  and  we  wish  to  bring  out  the  point- 
ing of  both  arms  in  both  directions,  we  can  easily  accomplish  this 
by  douching  the  opposite  ear,  first  with  cold  and  then  with  hot 
water.  In  this  way  we  leave  the  ear  that  has  the  dry  perforation 
as  much  alone  as  possible. 

Electrical  Test 

For  practical  purposes  the  electrical  test  has,  unfortunately, 
a  very  limited  usefulness.  Since  the  ability  to  examine  one  set 
of  canals  at  a  time  is  of  such  prime  importance  in  making  these 
tests  of  clinical  usefulness  it  is  evident  how  limited  are  the  uses 
of  an  agency  which  stimulates  at  the  same  time  not  only  the  entire 
labyrinth  but  the  VIII  Nerve  as  well  and  perhaps  even  the  medul- 
lary nuclei  themselves.  Also  whereas  the  normal  person  responds 
to  a  current  between  4  and  6  milliamperes  (m.m.),  which  is  not 
painful,  pathological  cases  require  such  a  strong  current  that  it 
is  distinctly  painful.  Fortunately  the  caloric  test,  by  fulfilling  all 
requirements,  makes  the  electrical  test  unnecessary  in  the  average 
case.  The  one  use  to  which  the  electrical  test  may  be  applied  in 
which  it  is  very  useful  is  in  making  a  differential  diagnosis  be- 
tween involvement  of  the  labyrinth  and  VIII  Nerve.  In  attacking 
this  problem  the  electrical  test  is  the  only  means  of  differentiation. 
In  a  recent  destruction  of  the  labyrinth,  the  caloric  test  will  fail 
to  produce  responses ;  the  electrical  current,  however,  will  directly 
affect  the  intact  VIII  Nerve  and  produce  normal  reactions. 


248  EQUILIBRIUM  AND  VERTIGO 

The  galvanic  current  is  used.  A  large  electrode  is  held  in  one 
hand,  a  small  one  is  placed  on  the  mastoid  process.  Both  elec- 
trodes should  be  covered  with  cloth  or  cotton  and  should  bo  kept 
fairly  saturated  with  a  normal  salt  solution.  (This  decreases  the 
unpleasantness  of  the  current.)  The  current  is  gradually  turned 
on,  and  when  4  m.m.  are  discharging  a  nystagmus  should  appear. 
Another  method  is  to  have  two  small  electrodes,  one  applied  to 
each  mastoid.  In  this  way  the  kathode  of  one  side  is  reinforced 
l)y  the  anode  on  the  opposite  ear,  in  the  same  way  that  both  ears 
are  stimulated  by  turning.  It  is  better,  however,  to  api)ly  the  cur- 
rent to  one  ear  at  a  time,  just  as  the  caloric  is  a  more  accui'ate 
test  than  the  turning,  in  that  it  examines  one  ear  at  a  time.  The 
quantitative  measurement  of  nystagmus  is  made  by  noting  what 
strength  of  current  is  required  to  produce  it.  If  the  anode  is 
placed  over  the  right  ear,  it  gives  the  same  reaction  as  cold  water 
douched  in  the  right  ear.  The  kathode  gives  the  same  response 
as  hot  water  douched  in  the  right  ear.  That  is  to  say,  the  anode 
on  the  right  ear  produces  a  rotary  nystagmus  to  the  left,  the 
katliode  on  the  right  ear  produces  a  rotary  nystagmus  to  the 
right.  Unlike  the  caloric  test,  however,  the  reaction  lasts  only  so 
long  as  the  current  is  applied. 

It  must  not  l)e  thought  that  a  routine  examination  of  the 
internal  ear  requires  all  the  preceding  tests.  In  the  average  case 
it  is  necessary  merely  to  fill  out  one  chart  and  the  examiner  then 
has  before  him  all  the  essential  data  of  a  routine  examination. 


CHAPTER    XIX 
EXAMINATION  OF  A  CASE  WITH  THE  USE  OF  CHART 

For  the  convenience  of  those  unfamiliar  with  these  tests,  a 
brief  resume  is  given  of  the  method  of  examining"  a  patient  and 
recording  the  findings  on  the  chart  (see  Chart  II).  This  chapter 
may  be  used  as  a  "read}-  reference"  to  be  followed  until  the  ex- 
aminer becomes  familiar  with  the  technic. 

We  will  consider  the  examination  of  a  normal  person.  On  the 
first  page  of  the  chart  are  recorded  the  chief  complaint  and  his- 
tory, the  examination  of  the  nose,  throat  and  ears  and  the  hearing 
tests.  The  normal  responses  to  the  hearing  tests  are  shown  on  the 
chart. 

On  the  second  page  of  the  chart  we  now  record  the  vestibular 
tests.  The  spontaneous  i)henomena  are  first  noted.  The  patient 
looks  to  the  extreme  right  and  to  the  extreme  left;  the  normal 
shows  very  little  or  no  nystagmus.  The  patient  then  looks  up- 
wards and  downwards,  the  normal  showing  no  nystagmus.  This 
is  recorded  on  the  chart  in  the  nystagmus  column,  after  "Look- 
ing to  the  Right,"  "Looking  to  the  Left,"  "Looking  Up,"  and 
"Looking  Down."  The  patient  is  then  told  to  close  the  eyes 
and  the  spontaneous  pointing  tests  are  taken  and  recorded  under 
the  pointing  column.  The  normal  is  always  able  to  find  the 
finger  and  this  is  recorded  by  the  letter  "T,"  which  signifies 
"touched." 

Turning.  Place  the  patient  in  the  chair  in  a  comfortable  posi- 
tion and  arrange  the  bracket  so  that  the  head  is  tilted  forward  30°. 
The  foot-pedal  is  released ;  the  patient  closes  his  eyes  and  the 
chair  is  then  turned  to  the  right  at  a  speed  of  two  seconds  to  each 
turn  for  ten  turns.  The  chair  is  stopped,  and  the  stop-watch  is 
immediately  clicked.  At  the  same  instant  the  patient  is  told  to 
open  his  eyes   and  look  at  a  distant  point.     The  nystagmus  is 

249 


^50  EQriLIBRIUM  AND  VP:RTIG0 


CHART  II  A 

Nanie  A.ge  Date 

Address 


Referred  by 
DIAGNOSIS:      ^tU*^ 


SUMMARY:       J} ,,'v,.u.,tJ.  A^L-fUZi<n*A^ ^    -i^ai^    >i*/u«.«£. 

Complains  of       sy/^v2X..*^ 

HISTORY: 

Dizziness  •/rtn/K.£^ 
Staggering     i/h^n^t^ 

Deafness  Jhru-J^ 

Tinnitus  ^,<r>^ 


NOSE;  ./f't^u.^j^o^ 

THROAT:       V/v>»^«^o^ 

PARS:  /  - 


Fistula        -^^  .oM^ 

Hearing  Tests  4     ^ 

A  13  A|    »  Ac     >      Be      =      n  Pol.  |    -f"  c«  I  •'**^         Gait'-/       ^   j. 

=  13  Ig"  Ac>Bc=.D  I+-  |-P**<t  l.j^  *^ 


EXAMINATION  \MTH  USE  OF  CHART 


251 


CHART  II  B 
TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 

Looking  to  RIGHTiuw  i^j-^  ^      Shoulder  from  above 

Looking  to  LEFT  I/^mi  fJ^f  ^  "^  MM- 

Nystagmus     ~Tifvui^ 


POINTING 


^^  RIGHT 


Looking  UP    «yr^<^«^ 
Looking  DOWN    t^xrv^g^ 


Vertigo      jy^^ 

Past-pointing      yf<rv-«- 

Falling       jy,n^ 

Romberg      -^*-^  oXt^n, 
Turning  head  t/ right    Au^<,M^^ 
Turning  head  to  left     -^-^  oSiZv^ 
Attempt  to  overthrow    ^,0/u.x^     A-lX-^-^^ 


LEFT 


To  RIGHT     ^ 

Amp.    ^if>-iy-^ 
Duration  (2. "/Sec. 


To  LEFT      .^ 

Amp.     xi-o-t>^ 
Duration  3l  <^Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus     ,//w<x*-«-^ 
Vertigo     J]roaiju-*JL 
Past-pointing      Jt't^uMjtA. 


To  LEFT 

Shoulder  from  above 


Nystagmus   -^''^^^^ 
Vertigo     ~y/'jf'hu^^c>X. 
Past-pointing     >/^>/U/K-i»-d 


/v  to-;^^^  fo'io  7^^^ 


/6     toA^  /A"to   ^-i^r 


DoucheRIGjHT   ^^ 
Amp.   '^i-e-*-4^ 
After        min.>/osec. 


Head  Backj,  ^ 

Amp.     'S<»-o-td 

icheLEFT  (^ 
Amp.  -^-^tr-d. 
After         min.A^Osec 


Head  Back     < 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus      -^o't-on.a.t. 
Vertigo      -yrt^u^uuiJ 
Past-pointing     ,/^»>UAia^ 
Falling     ^.t>A.^..^-<>^ 


Douche  LEFf 
Shoulder  from  above 

Nystagmus     v//-o>i-u«<x^ 
Vertigo     Jh-a^UA.^ 
Past-pointing      A^^a^^^a-vU, 
Falling       A-^a^a-vJ. 


^•'  iJ(,^i.r(o"\.oJ(.Oi&xr. 


/^■'to::^^? 


9  'to  T^icjizr 


B"    to^L/oto   ^^ 


252  EQUILIBRIUM  AND  VERTIGO 

watched,  and  the  instant  that  the  nystagmus  ceases  tlie  stop-watch 
is  again  clicked.  The  normal  person  shows  a  horizontal  nystag- 
nms  of  good  amplitude  and  of  24  seconds  duration ;  the  type  and 
direction  of  nystagmus  are  recorded  by  an  arrow  as  shown  on 
the  chart  after  the  words  "to  right."  Under  this  are  recorded 
the  amplitude  and  duration.  The  patient  is  then  turned  to  the 
left,  just  as  before,  and  the  nystagmus  recorded  after  the  words 
"to  left,"  in  the  nystagmus  column. 

For  the  pointing  tests  after  turning,  the  patient  is  again  turned 
to  the  right,  but  twice  as  fast  as  before — one  second  to  each  turn 
for  ten  turns.  When  the  chair  is  stopped,  the  patient  keeps  his 
eyes  closed  and  the  chair  is  held  firmly  by  the  foot-clamp.  The 
pointing  tests  are  immediately  taken,  first  of  the  right  arm,  then 
of  the  left  arm,  then  again  of  the  right  arm  and  again  of  the  left 
arm  until  he  no  longer  shows  any  past-pointing.  The  normal  per- 
son past-points  aj^proximately  12  inches  to  the  right  with  the 
right  arm  and  10  inches  to  the  right  with  the  left  arm;  this  is 
recorded  in  the  pointing  column  after  "turning."  "12  to  R" 
means  "12  inches  to  the  right."  The  first  pointing  of  each  arm 
is  all  that  need  be  recorded  as  a  method  of  routine  provided  that 
the  past-pointing  has  proven  normal  in  duration.  The  normal 
show\s  three  past-pointings  of  each  arm.  The  patient  is  then 
turned  to  the  left,  just  as  before,  and  the  past-pointing  is  recorded 
under  the  pointing  column. 

By  this  turning  we  have  tested  the  horizontal  canals  of  both 
ears;  the  normal  nystagmus  has  demonstrated  normal  horizontal 
canals  and  normal  pathways  from  the  horizontal  canals  of  both 
ears  to  the  eyes.  The  normal  past-pointing  has  demonstrated, 
per  se,  a  normal  vertigo,  indicating  unobstructed  pathways 
from  the  horizontal  canals  of  both  ears  through  the  cerebellum 
to  the  cerebrum;  also  normal  pathways  from  the  cerebral  motor 
cortex  through  the  brain-stem  and  cerebellum  to  the  upper 
extremities. 

Caloric.  The  head  is  kept  in  ilic  same  position  and  the  douch- 
ing then  tests  the  vertical  canals,  l)ut,  of  course,  only  of  the  ear 
douched.     Water,  68°,  is   introduced  into  the  right  ear;  at  the 


EXAMINATION  WITH  USE  OF  CHART  253 

second  the  douching  is  started  the  stop-watch  is  clicked.  The 
eyes  are  watched  carefully,  and  the  patient  is  told  to  look  down  at 
the  floor  occasionally  so  that  the  beginning  of  the  nystagmus  may 
be  instantly  noted  by  observing  the  little  blood  vessels  of  the 
sclera.  It  is  best  to  elevate  the  upper  lid  with  the  thumb,  but  it 
is  also  wise  frequently  to  press  the  eyelid  over  the  eye  to  prevent 
the  dryness  of  the  conjunctiva,  which  is  uncomfortable  to  the  pa- 
tient. At  the  instant  a  definite  nystagmus  appears,  the  stop-watch 
is  again  clicked.  The  tyi)e  and  direction  of  the  nystagmus  are 
recorded  by  an  arrow  shown  on  the  chart  after  the  words  "Douche 
Right."  Under  this  is  recorded  the  amplitude  and  by  referring 
to  the  stop-watch  we  note  how  long  it  took  to  produce  the  nys- 
tagmus. The  normal  person  shows  a  rotary  nystagmus  to  the 
left  of  good  amjilitude  after  40  seconds  douching. 

No  time  must  be  lost  after  the  nystagmus  has  been  observed 
before  doing  the  pointing  tests.  If  the  examiner  is  conducting 
the  test  alone,  he  should  leave  the  recording  of  the  nystagmus 
until  later.  The  normal  person  past-points  approximately  8  inches 
to  the  right  with  the  right  arm  and  6  inches  to  the  riglit  with  the 
left  arm.  This  is  recorded  in  the  pointing  column  under 
''Caloeic."  By  this  douching  with  the  head  upright,  we  have 
tested  the  vertical  canals  of  the  ear  douched;  the  normal  nystag- 
mus has  demonstrated  normal  vertical  canals  and  normal  path- 
ways from  the  vertical  canals  to  the  eyes.  The  normal  past- 
pointing  has  demonstrated,  per  se,  a  normal  vertigo,  indicating 
unobstructed  pathways  from  the  vertical  canals  from  the  ear 
douched  through  the  cerebellum  to  the  cerebrum;  also  normal 
pathways  from  the  cerel)ral  motor  cortex  through  the  brain-stem 
and  cerebellum  to  the  upper  extremities. 

If  the  examiner  is  satisfied  that  he  has  o))tained  a  normal  past- 
pointing,  he  should  never  repeat  the  pointing,  as  he  is  w^asting 
valuable  time.  Immediately  after  taking  one  pointing  of  each  arm 
he  places  the  patient's  head  backward,  quickly  observes  the  nys- 
tagmus, then  again  takes  the  pointing  of  each  arm  with  the  head 
maintained  in  this  position.  With  the  head  60°  back,  the  right  hori- 
zontal canal  being  tested,  the  normal  shows  a  horizontal  nystag- 


2o4  EQUILIBRIUM  AND  M:RTIG0 

mus  to  the  loft  of  good  amjilitude,  and  a  slightly  larger  extent  of 
past-pointing  than  that  obtained  from  the  vertical  canals  with 
the  head  upright.  These  findings  are  recorded  on  the  chart  after 
the  words  "Head  back." 

The  left  ear  is  then  douched  and  the  nystagmus  and  past- 
pointing  are  recorded  in  tlie  same  way  under  the  respective  column, 
lirst  testing  with  the  head  upright  and  then  testing  with  the  head 
backw^ard  60°. 


CHAPTER  XX. 

PRACTICAL  CONSIDERATIONS. 

Having  presented  in  considerable  detail  the  technic  of  examina- 
tion, we  are  now  in  a  position  to  examine  patients,  to  discuss  the 
relative  value  of  the  different  tests  and  to  consider  the  signifi- 
cance of  the  phenomena  brought  out  by  the  examination. 

The  Nose.  If  there  is  any  evidence  of  involvement  of  the  nasal 
accessory  sinuses  it  must  be  considered  as  a  possible  focal  infec- 
tion, responsible,  perhaps,  for  a  toxic  labyrinthitis.  In  the  same 
way  empyema  of  a  sinus  may  be  the  source  of  toxemia  or  may 
have  led  to  a  brain  abscess.  A  deviated  septum  may  be  exerting 
marked  pressure  on  the  lateral  wall  of  the  nose  and  may,  for 
example,  be  the  cause  of  the  headache,  instead  of  a  suspected  in- 
tracranial condition.  The  presence  or  absence  of  anesthesia  of 
the  nasal  mucous  membrane  may  be  tested  by  putting  a  tubular 
speculum  in  the  nose  to  prevent  contact  with  the  vestibule  and 
with  a  delicate  cotton-tipped  probe,  touching  various  areas  within 
the  nose.  Naturally  only  the  anterior  portions  of  the  nose  can  as 
a  rule  be  touched  in  this  way;  of  course  no  astringent  should  be 
applied  to  shrink  the  turbinates,  as  this  would  alter  the  natural 
tone  of  the  mucous  membrane.  The  special  sense  of  smell  is  also 
to  be  considered ;  in  diseases  of  the  anterior  nares  odors  are  lost, 
whereas  in  diseases  of  the  posterior  nares  both  odors  and  flavors 
are  lost.  In  testing  the  sense  of  smell,  solutions  of  different 
strengths  of  camphor,  rose-water  or  oil  of  cloves  may  be  used,  and 
the  patient  is  asked  to  smell  the  different  solutions  and  to  indi- 
cate when  he  first    detects  an  odor. 

The  Mouth  and  Throat.  In  obscure  cases  an  X-ray  of  the  teeth 
should  be  suggested  in  order  to  see  if  there  be  any  pus-pockets  at 
the  roots,  which  not  infrequently  prove  to  be  the  cause  of  a  focal 
infection.     Careful  examination  of  the  tonsils  in  the  same  way 

255 


^256  EQUILIBRIUM  AND  VERTIGO 

frequently  gives  evidence  of  a  possible  source  of  systemic  infec- 
tion. In  suspected  intracranial  cases  it  is  of  great  importance  to 
examine  for  paralysis  or  anesthesia.  Protrusion  of  the  tongue 
to  the  right  indicates  paresis  of  the  right  side  of  the  tongue,  show- 
ing involvement  of  the  right  XII  (hypoglossal)  nerve.  In  paralysis 
of  the  right  side  of  the  velum  the  uvula  is  drawn  upward  toward 
the  unaffected  side  when  the  patient  says  "Ah";  this  indicates  a 
paralysis  of  the  IX  (glossopharyngeal)  Nerve.  Examination  of 
the  larynx  may  reveal  a  paresis  or  paralysis  of  the  vocal  cords ; 
this  is  very  helpful  toward  diagnosis,  showing  that  there  is  an  in- 
volvement of  the  recurrent  laryngeal  nerve  of  that  side  and,  as 
is  well  known,  this  is  one  of  the  first  of  the  branches  of  the  X  Nerve 
to  become  affected.  Anesthesia  of  the  mouth,  faucial  pillars  or 
pharynx  indicates  an  involvement  of  the  IX  Nerve.  The  special 
sense  of  taste  may  be  tested  by  different  strength  solutions  of 
sugar,  quinine  or  salt. 

In  a  routine  examination  of  the  internal  ear  or  in  intracranial 
cases,  however,  examination  of  the  nose  and  throat  only  rarely  fur- 
nishes important  data.  On  the  other  hand,  the  ear,  of  course,  needs 
the  most  careful  and  complete  study.  For  example,  a  patient  being 
studied  by  a  ncnirologist  for  a  possible  intracranial  lesion  sud- 
denly develops  complete  deafness  in  one  ear;  on  examination  this 
proves  to  be  entirely  due  to  a  wax-plug  in  the  canal,  the  removal 
of  which  restores  the  hearing  perfectly.  Also  it  has  happened  in 
the  experience  of  all  otologists  that  obscure  intracranial  cases  have 
been  cleared  up  by  an  ear  examination  showing  an  unexpected 
and  latent  purulent  condition  of  the  ear  which  has  been  the  cause 
of  a  brain  abscess  or  meningitis.  On  the  other  hand,  many  cases 
complaining  of  vertigo  turn  out  to  be  due  to  acute  catarrhal  mid- 
dle ear  conditions  or  Eustachian  salpingitis,  the  relief  of  which 
(|uickly  cures  the  vertigo. 

It  is  well  to  note  the  presence  of  a  retraction  of  the  drumhead, 
because  if  it  is  close  against  the  inner  wall  of  the  middle  ear  the 
effect  of  cold  water  is  felt  by  the  semicircular  canals  much  more 
quickly  than  in  the  normal  ear  in  which  the  intervening  air  space 
necessitates  a  longer  time  before  the  labyrinth  is  chilled.    In  such 


PRACTICAL  CONSIDERATIONS  257 

instances  it  frequently  happens  that  after  douching  the  ear  with 
cold  water,  nystagmus  w^ill  occur  after  20  seconds,  which  is  only 
one-half  the  usual  time  required.  This  is  also  noted,  of  course,  in 
cases  of  perforation  of  the  drum  membrane  with  chronic  suppura- 
tion in  which  the  cold  water  comes  into  intimate  relation  with  the 
internal  ear.  On  the  other  hand,  in  cases  of  chronic  suppuration 
with  thickening  of  the  mucous  membrane  and  perhaps  the  forma- 
tion of  granulation  tissue  or  polyps,  the  response  is  delayed  be- 
cause of  the  longer  time  required  for  the  chilling  effect  of  the 
water  to  penetrate  into  the  labyrinth.  The  presence  of  a  per- 
foration of  the  drum  membrane  in  a  case  in  which  there  is  no  active 
suppuration  is  a  contraindication  to  douching,  as  it  might  possibly 
start  up  an  inflammatory  process.  In  such  cases  cold  air  can  be 
introduced.  The  actual  temperature  of  the  cold  air,  however, 
cannot  be  accurately  regulated  and  a  quantitative  examination  is 
not  possible.  Such  an  examination  merely  shows  whether  or  not 
the  labyrinth  does  respond,  but  it  does  not  allow  a  determination 
of  how  long  it  took  before  producing  the  responses. 

COMPAEISON    OF    TuRNING   AND    CaLORIC    TeSTS 

(1)  In  turning,  the  object  is  to  detect  the  duration  of  the  nys- 
tagmus and  the  vertigo  after  turning.  In  the  caloric  test,  on  the 
other  hand,  it  is  noted  how  long  the  douching  continues  before  the 
phenomena  develop. 

(2)  Turning  gives  much  more  violent  nystagmus,  vertigo,  past- 
pointing  and  falling  because  (a)  both  ears  are  necessarily  stimu- 
lated at  the  same  time;  (h)  the  mechanical  force  of  the  turning 
produces  a  more  violent  endolymph  movement. 

(3)  The  turning  stimulus  dies  quickly  whereas  the  caloric 
stimulus  continues  for  a  long  time.  The  chilling  or  heating  of  the 
wall  of  the  labyrinth  produces  a  continuous  current  in  the  endo- 
lymph for  an  average  of  two  minutes ;  during  the  continuation  of 
the  douching  the  endolymph  movement  becomes  stronger  and 
stronger  and  after  the  douching  has  stopped  the  chilled  portion  of 
the  labyrinth  gradually  returns  to  the  normal  body  temperature. 

17 


258  EQUILIBRIUM  AND  VERTIGO 

In  contrast,  the  mechanical  influence  of  the  momentum  produced 
by  the  turning  is  at  its  height  immediately  after  the  chair  is  stopped 
and  then  quickly  dies  away. 

(4)  The  caloric  test  affects  only  the  ear  douched.  This  is  its 
chief  use.  It  must  be  noted  also  that  the  vertigo  is  greater  than 
that  produced  by  turning,  because  the  information  from  the  one 
ear  conflicts  with  the  information  from  the  other  ear. 

(5)  Turning  is  a  sensation  to  which  we  are  all  accustomed. 
The  caloric  test  produces  a  disturbance  to  which  we  are  not 
accustomed. 

(6)  Vertigo  after  turning  has  the  primaiy  and  secondary  sen- 
sations. On  turning  to  the  right  the  patient  has  the  primary  sen- 
sation of  turning  to  the  right,  and  on  stopping  he  has  the  sec- 
ondary sensation  of  turning  to  the  left.  In  contrast,  after  douch- 
ing there  is  only  a  primary  sensation  due  entirely  to  the  douching 
itself  and  consisting  of  a  sensation  of  turning  in  one  direction  only. 

(7)  The  position  of  the  head  does  not  affect  the  subjective 
sensation  of  vertigo  produced  by  turning.  After  the  patient  is 
turned  to  the  right  he  has  a  sensation  of  turning  to  the  left  whether 
the  head  has  been  inclined  backward  or  forward,  if  the  head  is 
maintained  in  that  position  when  the  chair  is  stopped.  This  is  so, 
because  of  a  previous  experience  of  turning.  After  douching,  on 
the  other  hand,  the  position  of  the  head  has  eveiything  to  do  with 
the  resulting  vertigo;  douching  the  right  ear  with  the  head  back 
produces  exactly  the  opposite  vertigo  from  douching  the  right  ear 
with  the  head  forward. 

To   Guard  Against  Unpleasantness  to   the   Patient 

The  turning-chair  should  be  absolutely  steady;  its  base  must 
not  wobble,  because  the  irregularities  of  movement  will  obviously 
tend  to  make  the  patient  sea-sick;  for  the  same  reason  the  head 
must  be  put  in  the  desired  position  in  the  head-rest  and  maintained 
in  that  position  during  the  turning. 

In  performing  the  caloric  test  on  sensitive  people,  both  the 
hot  and  cold  water  should  be  ready  to  use.    The  sequence  of  events 


PRACTICAL  CONSIDERATIONS  259 

following  the  caloric  test  on  neurasthenics  or  '  4iigh-strung "  in- 
dividuals is  sometimes  as  follows :  After  douching  and  noting  the 
nystagmus  and  taking  the  past-pointing,  instead  of  having  the 
violence  of  the  sensations  die  away,  the  patient  begins  to  be 
nauseated.  It  is  usually  possible  quickly  to  note  the  nystagmus 
and  take  the  past-pointing  and  then  immediately  to  douche  the 
same  ear  with  hot  water;  this  will  almost  invariably  stop  any 
unpleasantness.  Care  must  be  taken,  however,  not  to  continue 
the  douching  with  the  hot  water  more  than  perhaps  ten  or  fifteen 
seconds,  as  otherwise  the  hot  water  itself  will  begin  to  produce 
its  own  responses.  Under  these  circumstances  while  douching 
with  the  hot  water  the  patient  is  asked  "Do  you  feel  all  right 
now?"  In  addition  the  objective  signs,  nystagmus  and  falling, 
may  be  watched  and  as  soon  as  they  begin  to  disappear  the  hot 
douching  is  discontinued. 

The  amount  of  testing  that  can  be  done  at  one  examination 
should  be  regulated  entirely  according  to  its  eifect  upon  that  par- 
ticular patient.  Phlegmatic  individuals  and  those  whose  lesion 
interrupts  the  normal  responses  frequently  permit  the  examiner 
to  complete  all  the  tests  at  one  sitting.  The  average  case,  how- 
ever, had  best  be  examined  on  two  or  three  separate  occasions. 
Our  method  is,  on  the  first  examination  to  take  notes  of  the  chief 
complaint  and  the  history,  examine  the  nose,  throat  and  ears,  take 
the  tuning-fork  tests  and  examine  for  spontaneous  nystagmus, 
spontaneous  pointing  and  the  various  falling  tests.  There  is  noth- 
ing in  this  series  of  examinations  to  give  the  slightest  alarm  to 
the  most  nervous  patient.  Perhaps  also  on  the  first  day  we  may 
examine  for  nystagmus  after  turning ;  this  gives  the  patient  some 
little  knowledge  of  what  the  chair  is  for  and  at  the  same  time 
reassures  him  that  it  is  not  anything  to  be  dreaded.  The  next 
day  the  past-pointing  after  turning  is  undertaken  and  then  the 
douching  of  one  ear.  The  douching  of  the  other  ear  may  be  done 
on  the  second  examination  if  the  other  tests  have  not  proven  un- 
pleasant to  the  patient  or  may  be  postponed  till  the  third  examina- 
tion. On  the  average,  two  examinations  on  two  different  days 
are  sufficient  to  fill  in  the  chart,  but  it  is  far  better  to  take  three, 


260  EQUILIBRIUM  AND  VERTIGO 

four  or  even  five  days  before  completing  the  chart,  rather  than 
antagonize  a  nerv^ous  patient  by  making  the  tests  unpleasant  to 
him.  Of  course  this  is  entirely  a  matter  of  studying  the  disposi- 
tion and  idiosyncracies  of  the  patient.  In  some  cases,  highly 
neurotic,  ignorant  or  difficult  to  manage,  it  is  best  to  do  the  caloric 
test  first  of  all  so  that  if  the  patient  refuses  further  examination 
we  will  have  performed  the  most  useful  of  the  tests.  With  a 
little  care  in  these  particulars,  however,  it  will  be  found  that  not 
one  patient  in  twenty  will  complain  of  any  unpleasantness 
whatever. 

If  the  patient  is  too  sick  to  get  out  of  bed,  the  ears  can  be 
douched  veiy  satisfactorily  with  the  patient  lying  on  his  back ;  the 
pillow  naturally  raises  the  head  slightly  and  puts  the  horizontal 
canals  therefore  in  an  exactly  vertical  position.  The  pointing 
can  be  undertaken  very  easily  by  having  the  patient  feel  the  ex- 
aminer's finger  at  a  point  alongside  of  the  patient's  thigh  and 
then  raise  his  arm  to  the  vertical  position  and  come  back  again. 

Value  of  Summaries 

During  the  examination,  as  we  record  the  findings  on  the  chart, 
it  is  very  helpful  to  dratv  conclusions  as  we  go  along  step  by  step — 
to  "face  the  issue"  on  each  test;  for  example,  after  examining 
for  spontaneous  nystag"mus  or  spontaneous  pointing  it  is  best  to 
write  down  immediately  what  these  tests  themselves  indicate. 
Again,  if  after  turning  to  the  right  there  is  a  horizontal  nystagmus 
to  the  left  lasting  16  seconds,  and  after  turning  to  the  left  there 
is  a  horizontal  nystaginus  to  the  right  of  8  seconds,  we  then  write 
immediately  "Suggests  impaired  right  horizontal  canal."  This 
is  exactly  the  reaction  that  would  take  place  if  the  left  horizontal 
canal  alone  were  functionating;  we  therefore  write  down  the  im- 
mediate conclusions  from  this  test  itself.  In  a  similar  way  if  after 
douching  the  right  ear  with  the  head  upright,  nystagmus  does  not 
appear  for  perhaps  a  minute  or  more,  or  if  the  amplitude  is  poor, 
we  write  "Impaired  right  vertical  canals."  If  after  turning  or 
douching  there  is  an   absence   of  past-pointing,  we  write  imme- 


PRACTICAL  CONSIDERATIONS  261 

diately  under  each  separate  test  what  that  failure  of  reaction 
would  indicate.  Then  after  all  the  tests  are  completed  we  have 
a  series  of  separate  conclusions  from  which  the  final  conclusion 
can  be  drawn. 

After  the  completion  of  all  the  tests  it  is  important  to  put  down 
at  once  the  logical  deduction  from  the  examinations,  paying  no 
attention  at  all  as  to  whether  it  seems  to  fit  in  with  a  common- 
sense  view  of  the  case.  If  an  apparently  normal  person  shows 
certain  deviations  from  the  normal  it  is  best  to  write  down  for 
example,  ''Suggests  lesion  of  the  right  cerebellar  hemisphere," 
even  though  one  should  feel  practically  sure  that  the  patient  had 
no  lesion  of  the  cerebellum  whatever.  The  next  examination  may 
show  that  it  was  entirely  a  chance  deviation  and  the  conclusion 
can  then  be  altered  accordingly;  on  the  other  hand,  if  the  devia- 
tions persist,  the  old  conclusion  should  be  adhered  to.  In  certain 
cases  of  this  type  in  our  experience,  time  has  demonstrated  a 
cerebellar  lesion.  It  is  essential  that  the  ear-tests  should  be  con- 
ducted for  themselves  alone,  disregarding  what  we  may  know  of 
others'  opinions  of  the  case  and  confining  the  report  entirely  to 
the  conclusions  suggested  purely  from  the  ear  vieivpoint. 

Methods  of  Remembering  Normal  Respoistses  from  the  Tests 

The  usual  routine  methods  of  examination  are — (1)  Turning, 
with  the  head  upright,  and  (2)  douching,  with  the  head  upright. 
If  to  the  RIGHT  {i.e.,  either  turning  to  the  right  or  douching  the 
right  ear)  everything  is  to  the  right — all  the  pointing,  shoulder 
from  above,  shoulder  from  below,  elbow,  wrist,  neck,  trunk  and  also 
the  falling — all  are  to  the  right.  The  deviation  of  the  eyes,  just 
as  all  the  other  responses,  is  also  to  the  right.  This,  however,  is 
the  slow  movement  of  the  eyes  to  the  right;  the  "recovery,"  the 
quick  component  to  the  left,  is  more  conspicuous  and  therefore  this 
phenomenon  is  termed  "Nystagmus  to  the  left."  The  vestibular 
pull  of  the  eyes,  however,  is  just  as  truly  to  the  right  as  all  the 
other  responses.  Vice  versa,  to  emphasize  this;  if  the  left  ear  is 
douched  or  the  patient  turned  to  the  left,  all  the  responses  are  to 


OQ^  EQUILIBRIUM  AND  VERTIGO 

the  left;  the  true  vestibular  movement  of  the  eyes  is  also  to  the 
left  although  we  speak  of  it  as  "Nystagmus  to  the  right."  In 
routine  examinations,  therefore,  it  is  helpful  merely  to  remember 

If  to  the  right,  eveiythins:  is  to  the  right. 
If  to  the  left,  everything  is  to  the  left. 

This  method  of  remembering  the  responses  is  useful  only  to 
the  beginner;  after  we  are  familiar  with  the  fundamental  physi- 
ology of  the  labyrinth,  and  recognize  in  what  direction  the  endo- 
lymph  is  moving  after  any  given  test,  these  suggestions  are  no 
longer  necessary.  We  simply  note  that  the  vestibular  pull  of  the 
eyes,  the  past-pointing  and  the  falling  all  occur  in  the  direction  of 
the  endolymph  movement. 


CHAPTER    XXI 
PATHOLOGIC  CONSIDERATIONS 

It  will  be  observed  that  up  to  this  point  we  have  dealt  only  with 
the  normal  hearing  tests  and  the  normal  responses  to  the  tests  of 
the  vestibular  apparatus.  We  now  discuss  the  abnormal.  We 
have  considered  only  the  anatomy  and  physiology  of  the  parts 
involved,  the  tracts  connecting  them,  and  the  methods  of  examina- 
tion of  these  tracts,  to  determine  whether  they  are  intact  or  not. 
We  are  now  concerned  with  the  interpretation  of  pathologic  find- 
ings— the  significance  of  deviations  from  the  normal. 

Interpretation  of  the  Findings  in  the  Auditory  Mechanism 


4         Ac  <  Be  >  n         C^  I  good         Gait. 
8        Ac  >  Be  =  n  !  good  , 


.7         Pol. 


'<: 


Weber 


+ 


indicate  catarrhal  deafness  u\  the  ISdght  ear.  Left  ear  normal.  In 
the  right  ear  the  low  fork  is  not  heard  at  all  and  the  middle  fork 
is  reduced  one-half;  this  is  characteristic  of  obstructive  lesions  of 
the  middle  or  external  ear — the  low  sounds  are  lost  before  the 
higher  sounds.  The  high  tones  of  the  C4  fork  and  the  upper  limit 
of  the  Galton  whistle  are  heard  perfectly,  showing  that  the  cochlea 
is  intact  for  the  upper  tones.  Air-conduction  is  greater  than  Bone- 
conduction  in  the  normal,  and  also  in  a  lesion  of  the  internal  ear. 
Here  Ac  Be  shows  an  obstructing  lesion  of  the  conducting  ap- 
paratus. Also  the  fact  that  the  Bone-conduction  is  greater  than 
normal,  shows  that  the  internal  ear  is  intact  but  there  is  an  ob- 
struction in  the  conducting  apparatus.  The  Politzer  test  being 
negative  shows  an  obstruction  of  the  right  eustachean  tube.  The 
Weber  test  being  lateralized  to  the  right,  shows  a  lesion  of  the 
conducting  apparatus  of  the  right  ear.  The  cochlea  and  VIII 
Nerve  are  evidently  normal,  as  the  high  tones  are  heard  perfectly 
and  the  Bone-conduction  is  greater  than  normal. 

263 


264  EQUILIBRIUM  AND  VERTIGO 

The  following  hearing  tests 


3 

A 

4 

Ac  >  Be  <  n 

C4 

poor 

Gait. 

34 

Pol. 

+ 

3 

8 

Ac  >  Be  =  n 

good 

•7 

+ Weber 

indicate  impairment  of  the  auditory  fibres  of  the  right  ear,  either 
in  the  labyrinth  or  VIII  Nerve.  The  low  tones  are  only  moderately 
imjDaired,  whereas  the  high  tones  are  markedly  diminished;  this 
is  characteristic  of  nerve-lesion,  in  that  the  low  tones  are  usually 
the  last  to  be  lost  and  the  high  tones  are  the  first  to  go.  Bone- 
conduction  less  than  normal  and  the  AVeber  lateralized  to  the 
normal  side,  both  show  involvement  of  the  receptive  apparatus. 
The  following  hearing  tests 


A     o 

3 


Ac?       Be? 
Ac    >  Be 


none 
good 


Gait. 


none 

•7 


Pol. 


+ Weber 


indicate  complete  destruction  of  the  auditory  fibres  in  either  the 
cochlea  or  VIII  Nerve  of  the  right  ear.  To  corroborate  this  diag- 
nosis it  will  be  found  that  the  200  fork  placed  upon  the  right  mas- 
toid process  will  be  heard  only  in  the  left  ear,  showing  that  the 
internal  ear  on  the  right  side  is  completely  destroyed.  In  order  to 
settle  the  question  finally  we  can  exclude  the  left,  or  normal  ear, 
and  then  test  the  right  ear.    This  can  be  done  as  follows : 

(1)  A  noise-apparatus,  such  as  the  Barany  model,  is  placed  in 
the  normal  ear ;  the  peculiar  noise  produced  completely  engrosses 
the  internal  ear  of  that  side,  in  this  way  eliminating  this  ear. 
Shouting  in  the  other  ear,  or  any  other  noise  whatsoever,  is  not 
heard  by  the  patient.  A  vibrating  tuning-fork  placed  at  any  point 
on  the  head  is  not  heard.  These  tests  have  shown  that  Air-con- 
duction and  Bone-conduction  are  both  completely  lost  in  the  af- 
fected ear. 

(2)  During  the  examination  of  the  ear  with  the  pneumatic  oto- 
scope, while  the  drum  membrane  is  being  moved  in  and  out  by 
pressure  and  suction,  this  ear  is  unable  to  hear  any  sound  by  Air- 
conduction;  so  that  any  shouting  that  is  understood  by  the  patient 
is  being  heard  by  the  affected  ear. 


PATHOLOGIC  CONSIDERATIONS  265 

(3)  Later,  during  the  vestibular  tests,  we  eliminate  the  normal 
ear  in  a  similar  way  by  douching;  douching  very  satisfactorily 
shuts  off  sounds  from  the  ear,  not  only  by  the  presence  in  the  ex- 
ternal canal  of  the  water  and  its  impact  upon  the  drumhead,  but 
also  because  the  actual  noise  itself  produced  by  the  douching  is 
sufficient  to  eliminate  that  ear. 

These  functional  tests  of  hearing  therefore  have  made  a  dif- 
ferential diagnosis  between  an  obstructive  lesion  of  the  external  or 
middle  ear  and  a  receptive  lesion  of  either  the  internal  ear  or  VIII 
Nerve. 

As  to  the  intracranial  paths  of  the  auditory  fibres,  they  un- 
fortunately give  us  very  little  information  of  value  in  locating 
lesions.  Randall  suggests,  however,  that  a  lesion  involving  the 
trapezoid  bodies  in  the  pons  would  be  capable  of  causing  complete 
binaural  deafness ;  his  reason  being  that  not  only  the  anterior 
fibres  enter  the  trapezoid  bodies  but  that  also  the  posterior  fibres 
from  the  acoustic  striae  come  forward  to  the  trapezoid  body.  A 
lesion  involving  both  these  bodies  or  the  fibres  between  them  would, 
according  to  this  view,  block  all  auditory  impulses  from  both  ears. 

*' Word-deafness"  consists  of  inability  to  understand  the  mean- 
ing of  spoken  words.  In  such  a  case  the  tuning-fork  tests  may 
show  perfect  hearing  for  tone;  the  spoken  voice  also  is  heard,  but 
the  words  are  as  unintelligible  as  if  they  were  in  a  foreign  Ian- 
guage.  This  indicates  a  lesion  of  the  cerebral  cortical  centre  for 
word-hearing,  which  is  generally  regarded  to  be  located  in  the 
posterior  part  of  the  first  and  the  adjoining  superior  portion  of 
the  second  temporal  convolutions.  ''Word-deafness"  in  the  right 
ear  is  suggestive  of  a  lesion  of  the  left  cerebral  cortex,  and  vice 
versa;  this,  however,  is  by  no  means  absolute,  as  unquestionably 
some  auditory  fibres  go  to  the  cerebral  cortex  of  the  same  side. 

Interpretation  of  Findings  in  the  Vestibular  Mechanism 

On  looking  to  the  right  or  looking  to  the  left  there  is  often  a 
slight  nystagmus,  due  to  a  wavering  in  the  pull  of  the  muscles  in 
this  extreme  position;  this  is  physiologic.    When  there  is  a  marked 


266  EQUILIBRIUM  AND  VERTIGO 

iij'stagnius  or  a  noticeable  difference  between  looking  to  the  right 
or  looking  to  the  left,  it  should  be  considered  pathologic.  A  spon- 
taneous nystagmus- of  any  type  or  in  any  direction  which  is  present 
on  looking  straight  ahead,  is  always  pathologic.  A  spontaneous 
vertical  nystagmus,  on  looking  straight  ahead,  or  looking  up  or 
looking  down,  is  indicative  of  a  lesion  involving  the  brain-stem.  A 
lesion  of  the  labyrinth  or  VIII  Nerve  never  produces  a  spontaneous 
vertical  nystagmus. 

Spontaneous  Vertigo.  A  continuous  vertigo  lasting  over  three 
months  is  strongly  suggestive  either  of  an  intracranial  lesion  or 
neurasthenia.  Vertigo  due  to  a  lesion  of  the  labyrinth  passes 
away  as  a  rule  in  a  few  days  or  weeks. 

Spontaneous  Pointing.  The  patient  occasionally,  through  care- 
lessness or  inattention,  will  show  a  spontaneous  past-pointing ;  sev- 
eral repetitions,  however,  will  prove  that  this  past-pointing  was 
not  pathologic,  but  merely  accidental.  A  spontaneous  past-point- 
ing of  the  right  arm  to  the  right,  suggests  a  lesion  of  the  inward- 
pointing  centre  of  the  right  cerebellar  hemisphere.  In  an  attempt 
to  find  the  finger,  there  is  lacking  the  restraining  influence  of  the 
inward-pointing  centre  and  the  past-pointing  is  therefore  outward. 
In  a  similar  way  a  spontaneous  past-pointing  of  the  right  arm  to 
the  left  suggests  a  lesion  of  the  outward-pointing  centre  of  the 
right  cerebellar  hemisphere.  It  is  usually  sufficient  to  examine 
only  the  upper  extremities;  however,  if  the  patient  exhibits  diffi- 
culty in  walking  or  standing,  the  lower  extremities  should  also  be 
tested.  In  obscure  cases  all  the  tests  may  be  carried  out  in  order 
to  examine  all  the  cerebellar  cortical  centres. 

Spontaneous  Falling.  A  patient  with  a  lesion  of  the  right 
labyrinth  tends  to  fall  in  the  direction  of  the  right  ear;  when  he 
faces  forward  he  tends  to  fall  to  the  right,  on  turning  the  head 
to  the  right  he  tends  to  fall  backwards  and  on  turning  the  head 
to  the  left  he  tends  to  fall  forward.  This,  as  a  rule,  is  not  true  of 
an  intracranial  lesion;  if  the  lesion  is  on  the  right  side  the  patient 
tends  to  fall  to  the  right,  and  if  the  lesion  is  on  the  left  side  the 
patient  tends  to  fall  to  the  left,  regardless  of  the  position  of  the 
head.  In  tlie  attempt  to  overthrow  the  patient,  we  discover  whether 


PATHOLOGIC  CONSIDERATIONS  267 

the  pelvic  girdle  shows  a  normal  swaying  to  the  opposite  side  in 
order  to  preserve  equilibrium;  if  the  pelvic  girdle  fails  to  re- 
spond, it  suggests  a  lesion  of  the  vermis  of  the  cerebellum  in  the 
area  presiding  over  the  pelvic  girdle. 


Failure   of   Reaction   to  Ear-stimulation 

It  is  the  absence  of  normal  responses  or  the  deviation  from 
the  normal  responses  that  gives  us  information  as  to  a  lesion  along 
the  path  of  those  particular  fibres  that  fail  to  transmit  the  im- 
pulses (see  Chapter  VI.)  Speaking  in  general,  if  after  stimula- 
tion of  the  ears  there  is  no  nystagmus,  a  lesion  is  indicated  along 
the  vestibulo-ocular  tract  which  should  normally  have  produced 
nystagmus.  If  there  is  no  vertigo  there  is  a  lesion  in  the  course 
of  the  vestibulo-cerebello-cerebral  tract,  which  normally  conveys 
to  the  cerebrum  the  impulses  producing  vertigo.  If  there  is  no 
past-pointing  after  ear-stimulation,  it  shows  either 

(1)  A  lesion  along  the  vestibulo-cerebello-cerebral  tract  just 
mentioned ;  in  this  case  the  absence  of  vertigo  naturally  causes  an 
absence  of  past-pointing.  It  must  be  noted,  however,  that  it  causes 
an  absence  of  past-pointing  of  all  extremities  in  both  directions; 
as  there  is  no  subjective  sensation  of  turning,  there  is  no  attempt 
of  any  extremity  to  past-point. 

(2)  A  lesion  along  the  pointing  tracts  themselves,  either  in 
the  cerebrum,  the  cerebellar  peduncles,  the  cerebellar  nuclei  or  the 
cerebellar  cortex.  It  is  to  be  noted  that  a  lesion  under  these  cir- 
cumstances would  involve  only  that  particular  pointing  affected 
by  the  fibres  involved.  For  example,  a  lesion  of  the  right  cere- 
bellar hemisphere  in  the  region  of  the  outward-pointing  centre, 
would  show  a  failure  of  the  right  arm  to  past-point  to  the  right, 
when  it  should  past-point  to  the  right ;  the  right  arm  would  past- 
point  properly  to  the  left  and  the  left  arm  would  past-point  prop- 
erly both  to  the  right  and  to  the  left.  This  makes  a  sharp  contrast 
to  the  lesion  mentioned  above  in  which,  owing  to  the  absence  of 
vertigo,  there  was  a  complete  absence  of  past-pointing  of  all  ex- 
tremities in  both  directions. 


268  EQUILIBRIUM  AND  VERTIGO 

Tlie  absence  of  falling  after  ear-stimulation  similarly  indicates 
a  lesion  either  of  some  portion  of  the  vestibulo-cerebello-cerebral 
tract  or  of  the  cerebro-cerebello-spinal  tract. 

Either  a  "perverted"  nystagmus  or  an  "inverse"  nystagmus 
is  indicative  of  involvement  of  the  brain-stem.  If  a  given  ear- 
stimulation  should  normally  produce  a  horizontal  nystagmus  to 
the  left,  and  under  these  circumstances  there  appears  instead  a 
vertical  nystagmus  upwards,  a  rotary  nystagmus,  or  an  oblique 
nystagmus,  we  may  speak  of  it  as  a  "perverted"  nystagmus;  if 
instead  of  the  normal  horizontal  nystagmus  to  the  left  there  occurs 
instead  a  horizontal  nystagmus  to  the  right,  it  may  be  termed  an 
"inverse"  nystagmus.  It  is  evident  that  under  these  circum- 
stances the  impulses  from  the  ear  have  been  conducted  to  the 
wrong  nuclei.  Xeither  a  perverted  nor  an  inverse  nystagmus  can 
possibly  be  produced  by  a  lesion  of  the  labyrinth  or  VIII  Nerve; 
a  peripheral  lesion  produces  a  poor  nystagmus  or  no  nystagmus  at 
all,  but  an  absolutely  false  response  would  of  necessity  indicate 
involvement  of  the  brain-stem. 

If  after  ear-stimulation  there  occurs  a  conjugate  deviation  of 
the  ej^es  instead  of  a  nystagmus,  this  absence  of  the  quick  com- 
ponent of  the  nystagmus  indicates  a  lesion  at  the  base  of  the  cere- 
bral crura  where  the  fibres  from  the  cerebrum  are  distributed  to 
the  ej^e-muscle  nuclei  or  at  some  point  liigher  up  along  the  cerebro- 
ocular  tracts. 

The  foregoing  shows  in  general  the  method  of  analysis  on  the 
basis  of  the  auditory  and  vestibular  tracts.  These  methods  will 
be  presented  in  more  detail  in  tlie  two  following  chapters. 


CHAPTER  XXII 
HYPOTHETICAL  CASES 

A  STUDY  of  the  differential  diagnosis  between  lesions  of  the  in- 
ternal ear  and  of  the  intracephalic  structures,  as  well  as  the  gen- 
eral subject  of  intracranial  localization,  furnishes  so  much  data 
that  the  analysis  of  any  given  pathologic  case  may  appear  very 
complex  to  those  taking  up  this  work  for  the  first  time.  Therefore, 
in  order  to  bring  out  the  fundamental  principles  in  the  analysis  of 
these  pathologic  cases,  it  will  prove  helpful  first  to  take  up  hypo- 
thetical cases,  putting  down  in  dogmatic  form  the  phenomena  to 
be  expected  from  a  lesion  in  any  given  location. 

The  method  of  approach  is  based  upon  the  tracts  previously 
presented.  For  example,  the  fibres  from  the  horizontal  semicir- 
cular canal  proceed  to  Deiters'  nucleus  and  divide  at  this  point; 
given  an  isolated  lesion  between  Deiters '  nucleus  and  the  posterior 
longitudinal  bundle,  all  responses  from  all  the  semicircular  canals 
would  be  normal  except  that  the  right  horizontal  canal  would  fail 
to  produce  nystagmils.  Similarly,  given  a  lesion  limited  to  the 
right  inferior  cerebellar  peduncle,  all  responses  from  all  semicir- 
cular canals  would  be  normal  except  that  the  right  horizontal  canal 
would  fail  to  ])roduce  vertigo. 

Of  course,  in  actual  pathologic  cases,  we  usually  find  that  more 
than  one  response  is  absent  or  impaired,  and  we  also  may  find  the 
added  difficulty  of  the  effect  of  intracranial  pressure  upon  some 
of  the  pathways.  If,  however,  we  first  master  these  hypothetical 
cases,  Ave  are  then  in  a  position  to  approach  the  study  of  the  actual 
cases  given  in  the  final  chapter. 


269 


270 


EQUILIBRIUINl  AND  VERTIGO 


Name 

Address 

Referred  by 


CHART  III  A 

Age 


Date 


DIAGNOSIS 


iOSlS:       >|Lt<^t<^c^      jLL'itA-^it^<n,^-     r^     Jv<ijwC  X<X^<>WAy-^ 


'./tx-i<^^^ 


HISTORY: 

Dizziness     ^  i^ ,  >x.a^AtJ.  . 

Staggering   ■ji-t',  yyt^ajiVLM^ 

Deafness    ^/^Jv/  ^    /f^^^^ 


Tinnitus     j^^ 


X«~^    ai   '.tJZZcA.    >-^     /l^^^  **^, 


Z^«-tX_     gjt^tK^OjL^ 


NOSE:  ^jt^,,j2U. 


THROAT:      v/T^-o.-^* 


A.  D.   -yf  Jt^,<x.i^<-*^ 

EARS:  /U  '      ^      ■ 

A.  S.     ^Z  x.<i Ay^^'^'^t' 

/ 

Fistula       ^JliJ.oJ*-*'^ 


jty^ 


Hearing  Tests 

Alo  A  I  o 

^13  1^ 


Ar      ?        Be      ?        n 
Ac      ?■       Be     =       n 


yjtil^^ 


J'ol.  I  — 


I  jV»ri 


Gait  I  o 


t: 


"^^ 


HYPOTHETICAL  CASES 


271 


CHART  III  B 


NYSTAGMUS 
Looking  to  RIGHT       yitn^ 
Looking  to  LEFT  hlajJuJ- 
Looking  UP       ^y/irvxt^ 
Looking  DOWN    t/f/^<. 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


POINTmG 


Shoulder  from  above 


RIGHT 


Nystagmus    "x^  A-c-^-vl-^^^*^    ^a   -yLjpX 
Vertigo      ^/r\^<Lt,^^  f 

Past-pointing      y^  /p^i,(^,    L^C/i  ..oa..^.,^ 
Falling       f.   T^^f 

Romberg      ,^    '^x.ifLC  , 

Turning  head  to  right   ^cjLti.    b-a^'^yC^^vn^irtC 

Turning  head  to  left      t-aJU<^    AvA-fyw^yt/ 

Attempt  to  overthrow    Axi^v-i^e,  -<iA^(i^<y,    ^»-o-t<^'"-<«X  A^O'Cl^.tn^yt, 


LEFT 


^r 


To  RIGHT    ^ 

Amp.     y^y^iL 
Duration   /^  Sec. 


To  LEFT 

Amp.      jo-fti- 
Duration    $  Sec. 


C7otr-t^ 


TURNING 

To  RIGHT 

Shoulder  from  above 


S"  to7;f|<i^4'to  %Jo^ 


Nystagmus    ><^M-^«xAx^    .tCju^oJZ^ry^  ^  UU-  ^g.^  Ai^-^.^Jit-Xi-^ 
Vertigo     ■^W.^^.^w^      ^,,,,^,_^/  r\ 

Past-pomfing      ^  ^  ^^^^ 


To  LEFT 

Shoulder  from  above 


3  "  to 


V'to  -C*^ 


Nystagmus      ,<i-^*/u2E*<..t<^ 

Vertigo        /j    ^  .k-^^u,..^*^/     Tf  >l*<u,vc*^«'  ) 

Past-pointing    J^  ^  ♦..cw.^.c^^Z       <i-,-^  *.*a/k^  .«^tA-i,<;Zl#^ 


Douche  RIGHT     A^-^^^ 
Amp. 
After  «^  min.        sec. 


Head  Back     -V^<rvi^ 
Amp. 

Douche  LEFT  ^=^ 
Amp.  -^tr-t-iL 
After         min.-ifosec. 


Head  Back   -6 

Amp.    ^,,.».^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus        -vV 
Vertigo  ^^ 

Past-pointing      ^.,.^„^ 


Douche  LEFT 
Shoulder  from  above 

Nystagmus   ,,/A.»-t't*<-«^ 
Vertigo      y^^y^.c^txA 
Past-pointing    o/^,,»>i,4^mv^ 
Falling      jy.,,1^^,^ 


jSa 


'a««c^     .'«L-t/ 


J^"  to7('.y^r5"to  ?^£^ 


tf^>0'-fcJ?A*«-^-'»'M^ 


<2.  "  to^^ 


m 


ip  "   toj^    f 'to    V/< 


y-  to-*^   f  "to  ^//- 


rrnm  Dr.  I,  H.  Jones'  Equilibrium  and  Vertigo. 


Copyright,  1918.  by  J   B  Lipp^ncott  Co. 


272  EQUILIBRIUM  AND  VERTIGO 


CHART  IV  A 

Name  Age  Date 

Address 

Referred  Ijy 

DIAGNOSIS:    Ji^l^'UArv-      ^-^^vio^V^     t^    y^<.b^     A^fiJtXtAA^  /J^j^cAm^    ou..^     yi-oMA-.^tyr- 


SUMMARY:      JM  yu^^^^ur^^^t^,    Y^y..:^,    Ir^-^j,, .  ^o^i - ^{^^^ZO^    .^..^    -iM^q 


Complains  of       ^'^^vx-^i-^li-vo-^ 


^q     *rp     JU./yty<l^. 


HISTORY: 

Dizziness  ~Jro 

Staggering  Jjr^ 

Deafness  /y 

Tinnitus  A. 


NOSE:  ~A't,n,J[l^ 

THROAT:      ytj^jcJZ^ 

A.  D.      ^'-^^  oJi^rC 
EARS:  /l'     rr 

A.  s.    -jrj^oo'XA*^<. 

Fistula       ^/rji43nX^,»>-c 


Hearing  Tests  0//  y 

A|3  A|?  Ac      >     Be     =      n  Pol.  |  +  ^^\9.U        (ialt,/  ^ '^ 

13  l§  Ac     >      Be     =      D  I  +  1-5^^  \.y 


HYPOTHETICAL  CASES 


273 


CHART  IV  B 
TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT     Jf/riA^ 
Looking  to  LEFT  M-oaAuL 
Looking  UP      Jr<r\y'-i^ 
Looking  DOWN     Jhin,^ 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 


^^o^a^ 


Nystagmus     ■"''>*^   X-iy-o-^C'i.^^A-a      7^  J\t/y^ 
Vertigo  ^4^^^  ' 

Past-pointing      J}-.,^^ 
Falling        //..^ 

Romberg     ^j2,.^:ii^ 

Turning  head  tcrright     V^JLajiX^A^t- 

Turning  head  to  left       •Jj'jt/ajC^Zv-i- 

Attempt  to  overthrow    ^'^<Xi^.^<x^  /i^a^<iZZ,v<M^. 


LEFT 


To  RIGHT    > 

Amp.      Vi^-Tji 
Duration  /la  Sec. 


To  LEFT    ^ 

Duration    c  Sec. 


TURNING 


To  RIGHT 
Shoulder  from  above 


t Z' \.o-j^ fi'lo  T^Jr 


Nystagmus    /oX^vi-^Gix^^    ,«6,<,^i,<JZC»»-<^ 
Vertigo  ^»yu..,.^»c/. 

Past-pointing      ^/^.»ax...^«v^ 


jj       To  LEFl' 

I       Shoulder  from  above 

Nystagmus    A2./*yiZiiAji^    ,MAAy<JZv^t^ 
Vertigo         .^^;>n.^..^.^^ 
Past-pointing      jf-,,A.,.,„.^_ 


/«■•  lo/^ 


/.3 


"t"  '^■^ 


j  CALORIC 

Douche  RIGHT    ^^~^  \       Douche  RIGHT 

Amp.     'Si-a-et  Shoulder  from  above 

After         min.V«sec.  . 

Nystagmus      ^/A>>-^^ 
Vertigo  Jrj,/u*^^-o^ 

Past-pointing    ^iy\.^^»Jt. 
Falling  Jh^^^^oJ^ 

Head  Back     h,.  }uj^ —  ^  A 


^tJ.    V-*jJ^7 


Douche  LEFT    ^O 

Amp.    -^lot^ 
After         niin.V<'sec. 


Head  Back   ^ 

Amp.    /jo-o^ 


ij     Douche  LEFT 

I     Shoulder  from  above 

Nystagmus     -^/Vu«4<fct 
Vertigo  c/f*.u,>.^ 

Past-pointing     Jl-^Ju,,,^ 


^-  Uil^^Ori,  "to  'T^^^ 


S'    to/yi   /O  to   V^ 


From  Dr.  I.  H.  Jones'  Equilibrium  and  Vertigo. 

18 


Copyright.  1918,  by  J.  B.  Lippiocott  Co. 


274  EQUILIBRIUM  AND  VERTIGO 


CHART  V  A 

Name  Age  Date 

Address 

Referred  by 

DIAGNOSIS:     J\^y(Uxrv(,     iV-Cj-^  fU-J^    W.     yr^^<^,     ^>-a^v*-»-L    ^CL^jg^fJi  ,  v<u^    ;tr 


SUMMARY:      J!^J£ 


Complains  of     ^ ry^rtyCe^Z^^iy^A^i 


HISTORY: 

Dizziness  ,yro 

SUggering  ^^ 

Deafness  \A'^ 

Tinnitus  ^a. 


NOSE:  ^^.J2CU 

THROAT :         ^fjLj  ^^X-t 
A.  D.      ^f  Jl-^  o^^^J-c 


f 


EARS:  A  __ 

A.  S.        •JtS-e)  ojL  v-C 


Fistula 


^t.^CyQ^^^"^^^*^ 


Hearing  Tests  ^  q/    f 

A|3  A|^  Ac     >     Be      =      n  Pol.|-^  c«  1 4*^        Galtl./         "^^^ 

I3  \S  Ac    >      Be      =     n  |^  |^^.,^  \^y  ^ 


HYPOTHETICAL  CASES 


275 


CHART  V  B 

TESTS  OF  THE  VESTIBULAR  APPARATUS 

SPONTANEOUS 


NYSTAGMUS 


POINTING 


Looking  lo  RIGHT 


A. 


<nd^ 


Looking  to  LEFT      /~V 


Shoulder  from  above 


RIGHT 


Nystagmus 


Looking  UP    >vuLy  ^  hiAci  ic*!  Vertigo       yirv^ii, 
^   /iajUjuaJ-  Past-pointing 


Looking  DOWN 


^ 


yC 


^ 


7r^  >vKw  -tcU     Romberg         >1»,U, 
U,  iMjt^      Turning  head  to  right    JhMj.-CtZZ^ 
0  Turning  head  to  left     JhjtJzCa^ 

Attempt  to  overthrow  ^,C-^    /^.^i**^  yn^tji^e  n^  .*t.<iXZ^^*yt^ 


LEFT 


To  RIGHT^ ^ 

Amp.    ^o-o-JL 
Duration  <2V  Sec. 


To  LEFT    -^ 

mp.  V< 


Amp.  "^o-o-i^ 
Duration  ;^y  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    .^•*'»-<*«-«-C 
Vertigo  yr/fu^M-cdt 

Past-pointing     jf\„/i,^aJi, 


To  LEFT 

Shoulder  from  above 

Nystagmus   -/rt'^-'^^aX. 
Vertigo  y}'»yuA<-a^ 

Past-pointing     yh^^^^i^a/. 


/i."Ao7^^tr/f>'to  l^tr 


fO"  to, 


i^/A"to  C^ 


Douche  RIGHT 
Amp. 
After  (J~  min 


M 


Head  Back    — ^ 

Amp.     xl*-b^ 

Douche  LE^      <0 
Amp.    "z^t-o-ii. 
After         niin.f^sec. 


Head  Back  ^ — 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 

Nystagmus       ^r-trn-t^ 
Vertigo  ^<-u*mv£ 

Past-pointing      ^.^,i„,,.,_aJ^ 

Douche  LEFT 
Shoulder  from  above 

Nystagmus      -^-.^kVix^^c^ 
Vertigo  --^^^^itc^-a.^ 

Past-pointing    ^.,^,u^^ 


^  "  toT^w^r  (o  to  7R^^ 
/o"  to;^jta'^"to7^^ 

^■'to^^fto.^ 


<P" 


/<»'  to  ''W^^. 


From  Dr.  I,  H.  Jooes"  Equilibrium  and  Vertigo 


Copyright,  1918.  by  J.  B  Lippincott  Co, 


276 


EQUILIBRIUM  AND  VERTIGO 


CHART  VI  A 


Name 


Age 


Date 


Address 

Uef.-rr.-.l  \,y 


DIAG 


AGNOSIS:    JsOJUaha^    J^^'  a^-*^-    ^    p 


-#V»^^/     -CtX^ 


£,o--,j,j-'v^    /-<^<yt-<^     >LAa,-r'    A._£-i!i<..«j.,tt     pii,i^ 


Complains  of     ^^VSaXo^^T 

HISTORY: 

Dizziness  ij.Ay^ 

Staggering  ,^;^<,^ 
Deafness         "^^^ 
Tinnitus  V<, 


«,^    '^t^^^jZ^i^C^^Q   yj  .£^<Ay 


^X^  i^-iyi'^-^    .«.<^     ;2v^i-<^^e^^W^      /^'"^ 


NOSE: 


^4'jUn„lZ^ 


THROAT:         ^/^U^-a^^-^*^ 


A 

A.  S 


p.       ^rjtya  ol/^^'tC 


EARS:  4  's   xjr    ' 


Fistula 


J^^aXw 


Hearing  Tests 

Al5  A|  ^ 

=  13  1^ 


\c     >       Be     ^      n 
Ac    >       Be      =     n 


Pol.  1  "/"  c*  I  '^trvtf-        Gait  1 .  7 


HYPOTHETICAL  CASES 


277 


CHART  VI B 
TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 


M 


POINTING 


RIGHT 


Shoulder  from  above 


Looking  to  RIGHT     v  7 -<n<^ 

Looking  to  LEFT     /^~^  \  P  J  - 

^  Nystagmus    ■<'^  .^.mv^^u^^    M     Ka^- 

Looking  UP    ^x-'W  -^v  >~^ -fa'^ertigo       if.\^  ^ 

^ /.x^^u.^- Past-pointing     .ti'^'^^     /UzJ_.aA^ 
K\  X  Falling      ti  7?^/^r-  ' 


/'  jt^1^<^U     /  "  fi^^- 


Looking  DOW: 


iing     .zr  7^^i£r- 

.,«y  ^Hv^^^  Romberg    ^^oM^   ^  J^^- 
^U£j^      Turning  head  to  right     Ud.  f  K^j^ 
I  Turning  head  to  left       2^>Mt,    Xi    y?i:biii- 

Atlempt  to  overthrow    >t.<.^^u,c.aZ    S^Lt,^*^,  ^axA^tLU  Ai'^<iuetCktyC 


LEFT 


To  RIGHT > 

Amp.     xfo-»iL 
Duration  cii/Sec. 


To  LEFT    -^ 

Amp.    -^(yo-tL 
Duration  oLiJ.  Sec. 


TURNING 


To  RIGHT 

ShoiJder  from  above 


Nystagmus      -^/■.,oa*.vc«^ 
Vertigo  yh.<^^L.c^<U. 

Past-pointing     ,/^,„^u^aZ 


To  LEFT 

Shoulder  from  above 

Nystagmus    ^/"xyi/w-c-A/^ 
Vertigo  Jh,,v>^jugJL 

Past-pointing    ^^^.i,,.,,^ 


/3  "    loi^/tr  ff  to  /^x^Zr 


f   to/1/^' // "to  ^r 


Douche  RIGHT 
Amp. 
After  c5"  min 


^. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


M 


Head  Back    ^ 

Amp.    A^„-,-iJi 

Douche  LEFT     I^T^ 
Amp.    -^o-o^ 
After         min.  4<;osec. 


Head  Back    .^ 

Amp.    ^.^r-t^ 


Nystagmus    -^f ^<n*.e--^ 
Vertigo  vyf,rv^ 

Past-pointing    J)-.r^^^ 


yi^trt^c^aJL  if\/Ci^<i 


Douche  LEP"1' 
Shoulder  from  above 


//"    yo'J^(f"^o7^-^ 


iJ^ 


Nystagmus     -y/>^u*^<uc 
Vertigo  Jl'.t^^i.^ffjt 

Past-pointing    .^^;;.,,^^^£ 


Falling 


/•■<^ 


6'"to  V^ 


From  Dr.  I.  H.  Jones'  Kquilibriiim  and  Vertigo. 


Copyright,  11)18.  by  .1.  B.  Lippincott  Co. 


278  EQUILIBRIUM  AND  VERTIGO 


Name 

Address 

Referred  by 


CHART  VII  A 

Age  Date 


DUGNOSIS:   4_    ^    /^y-//    ^-h^    ^..././^  ^:U^^. 


SUMMARY:    ^J^     //^^v.-o^*"-'-'-''**-   /.**'L^.-.<i/-,,W>2^^^^.«.<-^-*^,   ,^^<AZiao-      / ^^ . 


Complains  of       l/iAyCi,a  CT 

HISTORY:  ^ 

Dizziness  J^O^ 

Staggering  ^yt^y 
Deafness         ~yig 
Tinnitus  ~-y[_^ 


NOSE:  ^/Zi-^»Av^ 

THROAT:        ^rj^^^^C^ 


A.  D. 

A.S. 


^^^'=  ^X.»X:- 


Fistula 


Jfjyt,,,^/'yf-^ 


Heanng  Tests  ,,      >      Be     =      n  Po,.  j  -^  c' 1  f ^         Gait  1  ■  /  ^ 

=  1^  I?  Ac      >      Be     =      n  \  -h  \</^^  1-7  - 


HYPOTHETICAL  CASES 


279 


CHART  VII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT    -^rvyut^ 
Looking  to  LEFT     \/f.ay^4y 
Looking  UP  ^^tr.,^ 

Looking  DOWN,  ^h^r,^  . 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus    -^■ 

Vertigo  H<^ 

Past-pointing     ^Z..^    Z^ /^'qir      'Lxl  ^ 

Falling        *i  ^t^.  n       ' 

Romberg    J^Ji^  Z,    J^^CfJist 
Turning  head  to  right    ^^uZ,,    X  ^UXt" 
Tuming  head  to  left       /«-««-  :^  '^tZ^ 
Attempt  to  overthrow    V^ /^  •  ~^. 


/tt-o^^e^Ctl^vA/t, 


LEFT 


To  RIGHT 


-> 


Amp.   ^f~,yj. 
Duration  :2*^  Sec. 


To  LEFT    «- 


TURNING 


To  RIGHT 

Shoulder  from  above 


2"   \.o7\^i^(,io7^y^. 

Nystagmus    •  ^/'^'ixx.-aX 

Vertigo       -2/3    _/  >v^-u^„i-«^     f/6  /**^^»voe^.^ 

Past-pointing       ^  Yj  ^-  4.^^...^     UU  .c..,,^.^  .U^,^^< 


Amp.    '\lo-9-<l_ 
Duration  ^S^Sec. 


To  LEPT 

Shoulder  from  above 

Nystagmus    •y/' -e-'v^^^^-^^ 
Vertigo      .^    <^  -t<.<^i-uuu<»^ 
Past-pointing       /^    J7  a 


3-u^^'u>  /^r 


Douche  RIGHT    /'^ 
Amp.     '^o-o-ci 
After        min.  v^  sec. 


Head  Back    ■ ^ 

Amp.    /d<,-a-d. 

Douche  LEn^     *^ 
Amp.     do-t-tL 
After         niin.^dsec. 


Head  Back    ^ 

Amp.     -^o-.^ 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 

Nystagmus      -^-»'i-'-*<-^ 
Vertigo  ,^t>-ViA,..A^ 

Past-pointing    ^v>.*«c«^ 
Falling  ^c^u.,--ajL 


Douche  LEFT 
Shoulder  from  above 

Nystagmus      .y/vi**<.<«^ 
Vertigo  ^,«^u.».o<v/ 

F^din^"'"^"'*^    e/^,*^r^^ 


f  "    In^i^ir^'io^^ 


/"  to;^;, 


<!/■ 


'■OiAivJt/  ^a^y 


S"     to 


/-to  7^^ 

to   A:fU^- 


y"^oJ^f\o&f 


From  Dr.  I,  H.  Jones'  Equilibrium  and  Vertij 


Copyright,  1918.  by  J.  B.  Lippineott  Co. 


280 


EQUILIBRIUM  AND  VERTIGO 


CHART  VIII  A 

Nanie 

Age 

Address 

Refcrrcil  l>y 

DIAGNOSIS;      JsyC-OJ-^tnA,    ,^d^ 

/\L  'qMA    "H^<  cLiCcf,     tAJl> 

Date 


(^■o-i^'yiJ^ aiAji-^^^     /-0-^^~  /p^^iJ^^<^<-^      ijL-v..^       L o<.'^^^-'''^Q 


Complains  of       U X^A^Ckcr    ,  <^t-^<,-rC- 

HISTORV:  ^ 

Dizziness  vy -C^ 

Staggering  ^^^^ 

Deafness  ^ 

Tinnitus  ^ 


NOSE: 


^rA^a  x>M-*^~- 


THROAT: 

A.  D. 
EARS: 

A.S. 

Fistula 

Hearing 

Tests 

Al3           AM 

sts  ^  jL        H  W  94'AyU^ 

3  AM  Ac      >      Be      =      n  Pol.     -f-  '^'y^        Gait  1.  7  -/- 

Ac     >      Be      =      n  :   -/-  1  ^..^  I  .y^ 


HYPOTHETICAL  CASES 


281 


CHART  VIII  B 


TESTS  OF  THE  VESTinULAR  APPARATUS 
SPONTANEOUS 


M 


NYSTAGMUS 
Looking  to  RIGHT      ^lxn/'\yiy 
Looking  to  LEFT       y^^n.^^ 
Looking  UP 
l>)oking  DO\V.>     ^/^,,^-MX^ 


POINTING 


RIGHT 


Shoulder  from  above 


/    '    Zfj   /Ci^'o'iLf' 


/I  Nystagmus     -^'/^x-^ 

— ^Z<>-mj2.  Vertigo  >S^<l,e- 


Past-pointing      X^  7<(i'o-C^     Cf-o--C(^  ,«>i,-m-i^ 
N     Jr,6n^      Falling       ii  J?^.  U' 


Romberg      Zj  7?ca^ 

Turning  head  to  nfc4it  .cle-c^  ,u^   H-Ly,.^  ,.^^^u^ji.<IC^    J^  piUU-'-Jr^ 

Turning  head  to  left  '•  "  »  / 


Attempt  to  overthrow     'K^^.cju.iioL 


P^tv^^    ^^A^-d/f-    ,^jUK..£tC^^.^ 


LEFT 


A  J       ..     f 


To  RIGHT 


Amp.    ^/o-ft-«£, 
Duration^J.*/  Sec. 


To  LEFT     <- 


Amp.    X^tr^-^ 
Duration <X',/  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus       -^-*l^-<- «><- 
Vertigo  yroA^*^''-oJC 

Past-pointing     J^^^^u.,,.^ 


To  LEFT 

Shoulder  from  above 


Nystagmus       JrtA^^<M^ 
Vertigo  ^f'ty^A*^'^ 

Past-pointing      ^.oAyo,A^)Ji 


fy  to;^.^a // t'l  v^^ 


^"   u>I^^//"u^  -/dufi 


Douche  RIGHT     /^ 

Amp.    ^le^thd. 
After         min.VOsec. 


Head  Back,  =p- 

Amp.   -xJ^o-o-eL 

Douche  LEFT    l^^ 

Amp.     '^o-t-JL 
After         min.-y^osec. 


Head  Bat  k    ^ 

Amp-    -^o»^ 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 

Nystagmus     ^ /.yu-v^cLyL. 
Vertigo         ,4<rKi2. 
Past-pointing     y^,„_„.x. 


Douche  LEFT 
Shoulder  from  above 

Nystagmus     ^//Vu-u-o^ 
Vertigo       ^,„.,^^ 
Past-pomtmg      ^^^.^^ 


/  "  t-'T^^a  /"to  f^cj-^ 


(lJj 


f^yjLO^AA'^S^*^-^^ 


yto£//'lo^- 


From  Dr.  1.  H.  Jones'  Equilibrium  and  Vertigo. 


Copyright,  1918,  by  J.  B.  Lippincott  Co. 


£8^  EQUILIBRIUM  AND  VERTIGO 


Name 

Address 

Refeirod  l)y 


CHART  IX  A 

Age  l>iite 


DIAGNOSIS:    J,e<U<Tv^    Jl     /tLo-//   /u^jtA^i^^r^   A^uyx^-l^Jt'^^  ^ juC^k.^^^^^ ■ 
SIM.MARY:    '/^'a-L^     ^Co^ix^  o-wvZ«-C    -«x4^c^    Al^-A-^  -<^--t/^2^<^*^  A<5>^«^«-^«^     /]^^ 


/' 

Complains  of       6v  l/i^U^p      aX^o-^^q,  eVL-c-cx--^ 

7   ^/     / 


HISTORY:  ^ 

Dizziness  kJA.-'^ 

Staggering  5Cc^ 

Deafness  ^^ 
Tinnitus  ^^ 


NOSE :  ^fJ^  <^  '^ 

-IHROAT:  JrJi^^<^^-^<^ 

A.D.      ^-^^^ 

EARS:  ^./j^L^j:^ 

A.  b.  /f 


Fistula         ^/Ji^ 


^f,£^.a^C'^'''-t 


Hearing  Tests  Pol   1  "f"  C  I V^^^       Gait  U  /  ">- 

A  I  3  A  1  «  Ac      :;      Be     -      n  Pol.     "T^  / 

=  I  J  1  ^  Ac     >      Be     ^      n  I  -f-  l<7<^*^  /  — 


HYPOTHETICAL  CASES 


283 


CHART  IX  B 


TESTS  OF  THE  VESTIBULAR  AI'I'ARATUS 
SrONTANEOlIS 


NYSTAGMUS 


POINTING 


J. 


Looking  to  RIGHT      -''  "^"^ 
Looking  to  LEFT     Jrjrx^ 
Looking  UP         ^/r^rv^^ 
Looking  DOWN 


Shoulder  from  above 

t-pointing      ^^-6-S/     <kA^>^^^     ^  Afi.^-/i^ 
ing     ^  ^x^f  ^  / 


RIGHT 


Nystagmus     ^'/^o-*-^ 
Vertigo  o^c-o^ 

I  Past 

N     ^^Pirv^Ji-.         Falling     a^  f\x;a 

Romberg      '^•oJH^  ■&  ^'a/^ 

Turning  head  to  right    .t^^U^   ^U   ,<UZIy  ,<U,i4.^^zX^    /)    fcZl..^ 

Turning  head  to  left  „  .,  ,,  ••       •■        ^  .     ff 


Attempt  to  overthrow     >v,,t,i^^     Al/yx^    ^.L^i^lZt 


LEFT 


^  "  /2^7S^A- 


To  RIGHT  ^^ ^ 

Amp.     ■J'lr'ti-ii 
Duration  5  "^  Sec 


To  LEFT   <r 


TURNING 


To  RIGHT 

Shoulder  from  above 


^•■to7^,/;}/-^io  y^^ijc 


Amp.     ^o^>-<L 
Duration  tX^  Sec. 


Nystagmus    -vo'J't-K-A^ 

Vertigo    "^3  /ri   -k.c^lc«^        ( "=   A*<^<rw<!6<.)  | 

Past-pointing    ^    ^     U^r^^.U     l^U    ft^Ay^^^i  .U^Juu^t::^  . 

ToLEFr  !  ^ 

Shoulder  from  above  ^  "    to  /Aj^  ^   to   "X*-^ 

Nystagmus    ^«-i-***-^ 

Vertigo     ^    xT?   -tx.*nx*..-<v^       (^-^  au^tt^n^^tL^ 

Past-pointing      /^   ^  ^^.^a.,.,..^  ^^^    e*/MX^  ^Uy^A^cZC^ . 


Douche  RIGgT    ^^^ 
Amp.  -^S^y-t-JL 
After        min.Vosec. 


Head  Back^ > 

Amp.    'S'/^o-et 

Douche  LEFJf     «!^ 

Amp.   "^o-t-^ 
After         min.i/O  sec. 


Head  Back  <- 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


ll 


Nystagmus    t-'/>'i-t-^>^JX 
Vertigo      Jj^,,^^ 
Past-pointing        yf-,a~i-<JL 
Falling  jy,o-^^ 


Douche  LEFP 

Shoulder  from  abov< 


Nystagmus    <-vo-^t<..c-<i.^ 
Vertigo  Jh<,JU^.j^ 

Past-pointing     ^..j^,^^^ 


A-mP-   -^>*^ 


"to^/y- 


y"    to/J^L 


^  "   to(«^  (?"to  At^. 


From  Dr.  I.  H.  Jones'  Equilibrium  and  Vrrtigo. 


Copyright.  1918.  by  J.  B  LIppincott  Co. 


284  EQUILIBRIUM  AND  VERTIGO 


CHART  X  A 

Name  Age  Date 

Address 

Referred  by 

DIAGNOSIS:    A,Cyt^c<rv(y     ,t/J^     fr^^J^<XAJL      A.a'LyuJCio^      et-vcifet^      Pry     ■■(^^       /\e^/U-     oyu.,f— ,    C'l-' 

SUMMARY:      J^J-t    ^  ^L£-.v.^irvc.X,..^<i^    H-o^i^uL^^,     7wi2^ -n.«,^^,   l^^^-^<r     />,^  -L,^^.,.^!^ 


Complains  of     X^^e^   ^    ^e^^X.^     ^     ^aJU-    ^^^.^^   .<.^UxA^-x<..^^ 

HISTORY: 

Dizziness  vvV 

Staggering  >/}o 

Deafness  .//^ 

Tinnitus  ,^ 


NOSK:  ^f-Jl^ac^X^A^^ 

THROAT:        JTx-^oJZ^r^^ 


A. 

A.  S.      ^fZt-^  »X<^v-t 


Fistula        Jfj^^tt-t^-i. 

Hearing  Tests  ^  ^^'i/r'^r- 

A|3  AlS"  Ac>Bc=n  Pol.  |  -h  c«  I  ^»^  Gait  I  -  /  ^ 

"-13  1   S  Ac      >      Be     =     D  1-^  l-5.^*tjt  1./  - 


HYPOTHETICAL  CASES 


285 


CHART  X  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


Shoulder  from  above 


RIGHT 


POINTING 

LEFT 


NYSTAGMUS 

Looking  to  RIGHT      -VyVuX- 

Looking  to  LEFT      ^,rv^ 

Nystagmus    ^^rw^ 
Looking  UP         Jr_,B^^  Vertigo        ^<,>ct.  ^ 

Past-pointing    'J^i^a-tU-  ^cua^m-    jk  A/U4^ 
Looking  DOWN     J-^^         Falling     .^,,^^  ' 

Romberg     ^cJU^     i<,   /^ju^Jitr 
Turning  head  to  right   .doiji^  y^^  eX.x.,^t,   yU.<yiA.</C^\<    /L.    {I.^-jU-^..^ 
Turning  head  to  left  ■•  ■•  /  ,.  '..'(/. 

Attempt  to  overthrow    X,<v-u..c*^:^     Xc^vx^    ■o.^mIM.    ■ut-.o.^i^t:,,^,^ 


To  RIGHT    > 

Amp.    'zU-*^ 
Duration  £?<^Sec. 


To  LEFT     ,e 

Amp.    .$^,-«^ 
Duration  <2<,^Sec. 


TURNING 

To  RIGHT 

Shoulder  from  above 

Nystagmus  ./a'oa^-'.^  o-c 

Vertigo       -//-,..4-t*.^o^  ^ 

Past-pointing    .a/,^ajt*^  .//!    A^-«-^ 

Ij       To  LEFT 

Shoulder  from  above 

Nystagmus     -yh-t^w^'^ 
Vertigo        ^/r  0''\y'^^^-<^- 
Past-pointing    Jl-^o''vt*x,oJL 


c3;Zj^  ^^"'°  '^^'?-^ 


.o^H.*^    X^  A^-^-Ci^ 


/3"  to^     /A  "to    <ClM^ 


Douche  RIGHT    ^^ 

Amp.  'Z'-o-t^ 

After         min.  y^sec. 


Head  Back  ^ 

Amp.   -^it-t-yL 

Douche  LEFT     ^^ 
Amp.    -^jy-a-J 
After         min.</«'sec. 


Head  Back    ^^ 

Amp.   ^%-iH5^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


M 


v,oJL 


Nystagmus  ^r^'^'^^' 
Vertigo    ^.tAA^aX.  _ 

Past-pointing   oUy^ju^   -^  l^a-O^ 
Falling     ./^„>u,^^ 


I      Douche  LEFT 

Jl     Shoulder  from  above 

Nystagmus    -/rjy'UM-^x^ 
Vertigo       ..^^^L,,,,,^ 
Past-pomting     y?-^.,,,.,^,^ 


J"  to<^    (,\o/^IU- 


From  Dr.  I.  H.  Jones'  Equilibrium  and  Vertigo. 


Copyright.  1913»  by  J.  B.  Lippincott  Co. 


286 


EQUILIBRIUM  AND  VERTIGO 


Name 

Address 

Referred  by 


CHART  XI  A 

Age  Date 


DIAGNOSIS:     oO'^x^^-vO     ^  yxi-n<r*yv-<^     Ai>-t^t^;Zt*A-^     e^<..^*JZr\^    /j^    /r^A,/i/i   ,^tA**o^    aM^ 
SUMMARY :      — Yx^    y^[,Z<,.*'<'<'->»'-t-'i-'-^    .i^^<>n«>K-ev/-  ^   yi^fiX-o^a  -9Ti,„<,4._  V-l/lM^c^  ,  pa^  -  >d^-t^uj3t.i*^ 


HISTORY:  . 

Dizziness  ^yra 
Staggering  ^/^ 
Deafness     ./^ 

Tinnitus     ^ 


NOSE :        -yf-Jt^/o^^^^i^^ 
THROAT:       «^-y^^^^^^ 

EAR3:  /    ^      ^ 

A.  S.    ^fj^^a  .oX--^ 

Fistula       ^r^-<^^^^ 

""^'"aI?  A,^  a.      >      Bo      =      n  P0..1+  C  ||-^       OaU  |  /  ^ 

=  1^  1^  Ac      >      Be      =     n  1+  ^■^-'^  -7 


HYPOTHETICAL  CASES 

CHART  XI  B 


287 


TESTS  OF  THE  VESllBUf.AK  APPARATUS 
SPONTANEOUS 


Shoulder  from  above 


KIGHT 

3"  ti  '/l^^ 


NYSTAGMUS 

Looking  lo  RIGHT     ^fxrvyjU 

Looking  to  LEFT     ^h,<xuyt^  \  a 

Nystagmus    -//-ot~^ 
Looking  UP  Vertigo      .^xr^^ 

Past-pointing    ;^,ciH^  .o-ji..^     tc    /?x^-^ic~ 
Falling      ^^^^      ^  ^ 

Romberg     ^^  -oU,.,.^ 
Turning  head  t«  right    ^l-^a  aJL.^^ 
Turning  head  to  left       ^ jlL .^..Jz.,^^ 
Attempt  to  overthrow     k<Xc..,a^  yi^eA*-^  ^.oiJjU 


POINTING 

LEFr 


Looking  DOWN 


To  RIGHT 


^ 


Amp.    '^Iv-a-iA. 
Duration  SuSec 


TURNING 


To  RIGHT 

Shoulder  from  above 


/-^"to'^.yZr/oto  f^^&Jr 


Nystagmus     -^VUx.^^ 
Vertigo     ^.<.-iv*c<jX 
Past-pointing     ,/^,,^^o^^ol£ 


To  LEFT  < — - 
Amp.  Vtr-»-JL 
Dunition<:^<^  Sec. 


To  LEF r 
Shoulder  from  above 

Nystagmus    i/A.*-a»<>t.<a-C. 

Vertigo       ^j^^i^^^oJi 

Past-pointing   (JJ,^ijl-^^   r^   T^i^JU- 


3 "    *"^cj/ir/-ii''  ^-</i 


^  A<^ 


Douche  RIWIT    ^^ 

Amp.     j'-r-tL 

After         min.  V^o  sec. 


Head  Baik     > 

Amp.    ^„-r^ 

Douche  LEFT  (^ 
Amp.  yz>u-o-tC 
After         min.4<^<3.sec. 


Head  Back    < 

Amp.    ,^^o-w«/ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus    ^o-^u*^-*/^ 
Vertigo      J^.tr'iA^ojL 
Past-pointing    /t^.,yA^c<.^ 


Douche  LEFT 
Shoulder  from  above 


^-     u,J(,'^t>-'^o-f^^/x 


3 "  ^^^eJt^'^  ^^ 


Nystagmus    ^.o^^^-^"^ 

Vertigo    ^j^/u^a/,  p 

Past-pointing    OJ^Xt^L^U.  jr-1   f^-cb-U^  ■c^^'yu.    £o     A  <^4- 


l-r..oi  Dr.  I.  H.  Jones'  Equilibrium  aoJ  Vertigo. 


Copyright,  1918.  by  J.  B  Lippiacott  Co. 


288  EQUILIBRIUM  AND  VERTIGO 


CHART  XII  A 

Name  Age  Date 

Address 

Referred  by 


DIAGNOSIS: 


X(A<Lc<rvo  >-^    'V'k '^^  /a<.JU^    ^   t'-tyt/*w-<^«'    ./^    OM.     (M^/iAyC'l/^i'-^.-''^  ■ 


SUMMARY:   yf^/iZ<L^yyi^,i,o^ ^  1h<Al<4t^   <Xy^J^    j^cL^cU  -  A/y'-x'^^'-y^    <?y^  KXA.^^-^-^ ,  .<a^-«^ 


Complains  of      ^-o-u^'  ^  j^.trvXZtyC     ^y£     3^!ZI^vc^ 


HISTORY:  . 

Dizziness  ^fo 

Staggering  J/,<>^ 

Deafness  A^. 

Tinnitus  _^^ 


NOSE:         ^'jL^<^M^*j-L- 


THROAT: 


7 

I.  D.      t//-(to aJZ-</^ 


EARS:  A''     -r^ 


A.  D.      t^'-^' 
A.  S.      Jt-O^c 

Fistula      -'^.aZw. 


Hearing  TesU                                                                                                                    ^                                       ^AyC%^ 
Alj"          Al^           Ac>Bc=n                Pol.  I    -f-           cM  ^^        Gait  1  •  /             -^ 
"1^  I  g-  Ac     >       Be      =      n  I    -^-  l-^.^*^  1./  


HYPOTHETICAL  CASES 


289 


CHART  XII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT    -^. 
Looking  to  LEFT     <^- 


trujC^ 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 


Looking  UP 


A 


truJL 


Looking  DOWN 


Nystagmus      -//-o^^X 
Vertigo       rJr<rvdi 
Past-pointing      ovovi^. 
Falling     /a,£/t.    ^    fi-^l^ 

Romberg     ">^ajiM/   I,  f^<,ol4 

Turning  head  to  right    X„ui^    A   :^xi  // 

Turning  head  to  left     faUf^    ^   /^Jq-^ 

Attempt  to  overthrow  ^t,^„^      ^^^^    |,^,^   Z;    M-t^ 


To  RIGHT   ^ 

Amp.    Ut>-t^ 
Duration  A,  </  Sec. 


To  LEFT    «s^ 


TURNING 


To  RIGHT 

Shoulder  from  above 


/4'to^,^/fr/0to  1^^^ 


Nystagmus     yf- *^i<^-^-aZ- 
Vertigo     tZ/'-.o-'UtMsi.^ 
Past-pointing     t/A>>u....,»-o 


Amp.  'y,-tJi 
Duration  <iv^  Sec 


To  LEPT 
Shoulder  from  above 


/<J"  to/t^ 


/2'to   <^ 


Nystagmus    ^r  cy'UtJ-a^  i 

Vertigo     Jl^^^^^u^o^ 

Past-pointing    ^,/u^a£  ^  \ 


Douche  RI«IT    ^^ 
Amp.  '^j-<r~^r-«~- 
After         min.//Osec. 


Head  Back    ^ 

Amp.    /%-^ 

Douche  LEFT  ^ 
Amp.   -^U-ott 
After         min.  i^sec. 


Head  Back     -^; — 
Amp.   -ti^y.,.^ 


Fror-.  Dr.  I.  H.  .Jones'  Equilihr 

19 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 


5^"   to7^i^(*^^"to  ?^^^ 


Nystagmus   t/fe,A.uj^_^ 
Vertigo      -/h^AA...^ 

Past-pointing     •/!■  c-\.^.Mi,oJi  ^ 

Falling    ^U^...^  ^  .w.,rx.»<z^    fajeC^^  .r^  R<^^'-^  e<^,w<^    ^'  ^^ 
^^^— ^  f--  <^  ,f^  ^  /o^-fA'  1"^  ■•  ''''??'^'  ^"'°  ^'?'^       .Ti^-^-w, 

Douche  LEPT  ^ 

Shoulder  from  above  (^  "  ioXtlf.    S    to  \<f^ 

Nystagmus      -^,<yi<~-a.£ 

Vertigo       4-^„^^Ji 

Past-pointing     yy^A.       P 

Falling     :/)-,^_^    i'.^.^^^-    i^  6-M-  fl    \         .       /i 


lid  Vertigo 


Copyright.  1918.  by  J    B   Lippiocott  Co. 


ogo  EQUILIBRIUM  AND  VERTIGO 


CHART  XIII  A 

Name  Age  Date 

Address 

Referred  by 

DIAGNOSIS:     '\^<.u„^   ,^  .Jx..tA^^iA..cJZ,,^    ^    «uy{ir^L<^     ^^.<ylA^U^<x^  /AU.-....^-i£'^ 
SUMMARY         /.  yi/^  ^o..w<>^/,    -i-o^cZ,    x^aAA^  ,    /A*^    ^  ^ n.a-'iU.*-*^  ,^^<,ytZZ^a-  , 

/  ^ 
Complains  of       ^/iA'i<-^a.cr    .oa^l^ 


HISTORY :               ^ 

Dizziness       ^A^^ 

Staggering      ^.^.t^ 
Deafness         Vvo' 
Tinnitus           ■)|^ 

NOSE :            ^(t^^oMy^r<^ 
THROAT:       Jfjuo^x^M^^ 

A.D.      ^7--^^ 
EARS:                   /I  ^      ^ 

A.  S.        ^ IJi'tiyO-^^^^^'^ 

Fistula 

Hearing  Tests 

AI3          Al   S^ 
=  13              l^f 

Ac      >     Be     =     n 
Ac      >      Be     =     D 

Pol.  1-^  c'l^-^^      Galtl./  ^ 

1-^-  ;x.^  1.7        _ 


HYPOTHETICAL  CASES 

CHART  XIII  B 


291 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT     v/Z. 
Looking  to  LEFT     Jf/r^ 
Looking  UP       -^/Vi..-e- 
Looking  DOWN    Jir-^r^-A^ 


POINTING 


RIGHT 


Shoulder  from  above 


Nystagmus    •yrovJ-^ 
Vertigo       hjv.'cy<iAy'^ 
Past-pointing    Vi..<rv-^ 
Falling    ^o-v^ 

Romberg 

Turning  head  to  right     yiA^o^^^^^-^^^, 

Turning  head  to  left       y^tAn  /<l^4^ 

Attempt  to  overthrow     y<M[^>M.aL    ^iM/^^t-   oaaMu  W.^l^c;-^^'-**^  . 


LEFT 


/ 


TURNING 

To  RIGHT  I       To  RIGHT 

Amp.  [        Shoulder  from  above 

Duration  iJ.  YSec. 

Ac    -n^Oi^^^...^    UJr  ^    Nystagmus   ;^<7wi.,  (rU~  ^ 

■J         1  ,  y_  Vertigo      u/r<rvj!_- 

tt^o^i^a  iK^    xCcAj^JtyCO^  aS'  Past-pointing     ^AurvJt^ 

To  LEFT  I       To  LEFT 

Amp.  Shoulder  from  above 

Duration  iy^Sec. 

Ac   h^AX^n^.o^    ^'-^   ^  Nystagmus    )?<n^,    Lj- ^ 

^.^y^c^   .:^^^c.JU^  Past-pointing        ^i^,^ 


yOyy^cZuL^  -J.tri/'^A.JUjt.tf' 


.4«-L-«4.<^<-<^  (T»X« 


"^j4-<^<'^C 


^-ir^K.-yo^Q 


'^m^^cJUci 


^Ti 


Douche  RIGHT 
Amp. 
After         mil 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


'^o    -n^fiX^ 


^tV^A^I^^ 


U.\- 


Nystagmus   Jtrrw^i  (haA- 
Vertigo     Atn^j^. 


i^^T^Alr  /     ''      ^         Falling       ^^^ 

'   Head  Back   (Sny^ja^    «^t<;^,«Xi^   /^  J^^-^^jf 


^-0-v<^<X'^, 


QjZ^U. 


u. 


Douche  LEFT  Douche  LEFT 

Amp.  Shoulder  from  above 

After         min.        sec.  | 

^4v    yu^ffZ^,,...^  LU-  ^  Nystagmus^«^ 

''^Head  Back 
Amp. 


T^r 


Falling       Jh^^ 


CJ/^,rXJ,yaZjl^cL^ 


From  Dr.  I.  H.  Jones'  EquUibrium  and  Vertigo. 


Copyright,  1918,  by  J   B.  LipptDcott  Co 


292  EQUILIBRIUM  AND  VERl  IGO 


CHART  XIV  A 

Name  A^ge  Date 

Address 

Referred  by 

DIAGNOSIS:      C_^    ](^^U     ^^...A^y^cX    ^U 

SUMMARY:    S/^   ^^    -J^.jll-^,    7{^U   A^.^  .AZ^..w/ /.^   ^   ..^ 


Complains  of 
HISTORY: 


U/^M^o  ,  AZZa^i/u.^^  ,  x/<W^t<,^^t«/  ^^    7?Li,'dj.  ^C^i^,    -i^.xL^iU..Ujt^  . 


Dizziness  ^^t^/ 
Staggering  ,^^^^ 
Deafness        t;^^     _   ^      /^   ^^^ 


NOSE :       ^fjUs  Ai'^ii'^ 

/ 
THROAT :      "^'-^  *  ^^ 

A   D.    ^/ -1-^ c~-L*^v-ff 
EARS:  /  i^  ..-^ 

A.  S.      JriLqoM^-t-t, 


Fistula     -^-j2^(5c-^^«K. 


7' 

Hearing  Tests  HjU..^ 

A  I  O  A  I  O  Ac      r      Be     f       n  Pol.  |  —  c«  I  Gait  I  O  ZZ__ 

=  1^  '?  Ac     >       Be     =       n  1^  i  \.J  ^/^; 


HYPOTHETICAL  CASES 

CHART  XIV  B 


293 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT    ~A Cn^Jl. 
Looking  to  LEFT  }KixaMjJL   • 
Looking  UP       J 
Looking  DOWN       ^ 


POINTING 


Shoulder  from  above 


^__RIGHT 


Nystagmus  ,<rv^  x^^JiMiyo   l«    ^*^  a— ^  ,«x^  jU-t^Cu^'M  uJ,  tn^wL  ^ct-j^ 
Vertigo    it^  /  /      '^'^ 

Past-pointing    y^urwc^ 
Falling      t^  ^dx- 

Romberg     jcJUU/  X*    /^t^-,^- 

Tuming  head  to  right     jdjU   ^-tx,<:iLwL<rz^ 

Turning  head  to  left    J-aUM.    ^-i-vr-iv-r«i 

Attempt  to  overthrow     >i-i>'u>,oa^    Aa--^-^''^^   ^.ui^jCt.  rrXautZZa>^L^<l^ 


LEFT 


To  RIGHT 


^ 


Amp.    ^.oaJu 
Duration  /  (e'sec 


To  LEFT  ^<:C~ 
Amp.  ^J  o^jjt. 
Duration    g'  Sec 


TURNLNG 


To  RIGHT 

Shoulder  from  above 


Nystagmus  "^  t/l  i^^*'^^'-^'^'- 

Vertigo    ^^  ^  -.^»/u.— <v/-      ( /k  ^U4^-v^-cLt..^ 

Past-pointing     -^    ^    i.o«^u«-«.^ 


To  LEFT 
Shoulder  from  above 


g-  *oj(,.^ii," to  l^ir 


J"toj(x^^'(o/2^. 


Nystagmus  /3  /I  *,*A^i.<-t,«t/- 

Vertigo     /^    <rt    H..^u.--«-^     (^f  A*.«*v..*^; 

Past-pointing   ^ y^   ^   .^^u^^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


'V»vc^<1'A3^<, 


Douche  RIGHT       ^,n^^ 
Amp. 
After  (^  mm.        sec.  i 

Nystagmus     ^r^n^Ay  \ 

Vertigo     Jl^.vv^Ay 

Past-pointing     >^^r^.^  \j^^,Jy- 

Head  Back      ^.  ^,,^__,    ^   ^^^      -^    T^  ^^_^        „^  , 


Amp. 


'Viy/J'O^y 


Douche  LEFT     ^.n.,^ 
Amp. 
After  »5"  triin.        sec. 


Head  Back    < 


From  Dr.  L  H.  Jones'  Equilibrium  and  Vertigo. 


Douche  LEFT 
Shoulder  from  above 


Nystagmus    v^-^rn-fc 

Vertigo     Jj^jn-jt. 

Past-pointing     sA'j^^^ul,  ^^       . 


^  rv*-'*,'^^''*^ 


^/<r\*.ye.-Ujt'^ 


^^uZ^JUx 


Copyright,  1918.  by  }.  B.  Lippiocott  Co. 


CHAPTER  XXIII 

PATHOLOGIC  CASES  ANALYZED 

By  Lewis  Fisher,  M.D. 

It  is  presumed  that  the  reader  has  made  himself  thoroughly 
familiar  with  the  proper  technic  of  the  vestibular  tests  and  with 
the  sigiiilicance  of  the  various  findings  obtained  as  presented  in 
the  previous  chapters.  With  the  data  properly  recorded  on  a  chart 
so  that  all  the  salient  features  of  the  examination  can  be  taken 
in  at  a  glance,  how  are  we  to  proceed  with  the  actual  analysis  of 
a  case?  The  first  problem  in  any  given  case  is  whether  we  are 
dealing  with  a  functional  or  an  organic  condition.  If  the  chart 
shows  all  responses  to  ear-stimulation  perfectly  normal,  a  func- 
tional condition  may  be  suspected.  When  the  responses  obtained 
on  stimulation  are  not  normal,  the  case  should  be  considered  as 
having  an  organic  lesion.  Such  a  deviation  from  the  normal  need 
not  include  all  the  responses.  An  impairment  of  even  one  response 
shows  that  we  are  probably  dealing  with  an  organic  lesion. 

Having  concluded  tliat  the  case  presents  an  actual  organic 
involvement  of  the  vestibular  apparatus,  our  next  problem  is  to 
determine  whether  the  case  is  one  of  peripheral  or  central  lesion. 
This  is  the  most  important  and  at  the  same  time  most  difficult  dif- 
ferentiation that  the  otologist  is  called  upon  to  make.  Many  cases 
of  cerebellar  lesion  or  tumors  of  the  cerebello-pontile  angle  present 
symptoms  similar  to  those  observed  in  an  affection  of  the  laby- 
rinth— the  miscalled  "Meniere's  disease";  on  the  other  hand, 
labyrinthine  lesions  not  infrequently  simulate  cerebellar  affections. 
The  findings  obtained  upon  ear  stimulation  are  frequently  the  decid- 
ing factor  in  the  diagnosis,  and  it  therefore  behooves  the  otologist 
to  exercise  the  greatest  care  in  determining  this  point.  This  sul)- 
ject  is  discussed  in  great  detail  in  Chapters  VI  and  XXI,  but  i^ 
might  not  be  amiss  to  emphasize  a  few  of  the  most  important  prin- 
ciples in  this  differential  diagnosis. 

294 


PATHOLOGIC  CASES  ANALYZED  295 

In  a  peripheral  lesion  all  the  responses  are  impaired,  and  con- 
versely the  presence  of  any  one  normal  response  to  stimulation 
suggests  a  normal  labyrinth  and  VIII  nerve.  A  spontaneous  nys- 
tagmus in  the  vertical  plane,  either  upward  or  downward,  indicates 
a  central  lesion.  If  stimulation  produces  a  "perverted"  nystagmus 
then  again  the  lesion  is  i)robably  central. 

If  the  findings  lead  to  the  conclusion  that  the  lesion  is  central, 
then  our  next  problem  is  to  attempt  to  locate  the  lesion  more 
definitely  within  the  cranium.  The  facility  w^ith  wdiich  one  is  able 
to  do  this  depends  in  a  great  measure  upon  how  well  he  can  visualize 
the  various  pathw^ays  constituting  the  vestibular  apparatus.  The 
simplest  method  of  procedure  is  that  of  elimination.  We  begin 
with  the  labyrinth  and  proceed  brainward,  considering  each  struc- 
ture by  itself.  With  good  hearing  and  one  or  more  responses  on 
stimulation  of  the  kinetic-static  portion  of  the  labyrinth  normal,  the 
labyrinth  itself  and  VIII  nerve  may  be  considered  uninvolved.  For 
information  relative  to  the  medulla  oblongata  and  inferior  cere- 
bellar peduncles,  we  examine  the  responses  obtained  on  stimulation 
of  each  horizontal  canal  separately.  This  test  is  performed  rou- 
tinely by  tilting  the  head  back  60°  after  douching.  If  this  produces 
normal  horizontal  nystagmus  and  vertigo  with  past-pointing,  these 
structures  are  probably  not  involved.  To  determine  the  integrity 
of  the  pons,  we  examine  the  responses  obtained  from  the  vertical 
semicircular  canals.  These  are  tested  when  the  ear  is  douched 
with  the  head  in  the  so-called  "upright"  position.  If  the  chart 
shows  a  normal  rotary  nystagmus  with  vertigo,  past-pointing  and 
falling,  it  suggests  uninvolved  pathways  in  the  pons  and  middle 
cerebellar  peduncle  of  the  side  douched.  The  cerebellum  may  be 
considered  as  not  the  seat  of  any  gross-  lesion,  if  stimulation  of 
either  ear  or  any  canal  produces  a  past-pointing  of  both  arms  in 
both  directions.  " 

With  the  chart  critically  examined  in  this  manner  and  all  the 
possible  points  of  involvement  along  the  nerve  tracts  in  mind, 
w^e  attempt  to  find  one  location  the  involvement  of  which  would 
satisfactorily  account  for  all  of  the  impaired  responses.  Thus, 
when  the  stimulation  of  all  the  semicircular  canals  of  both  sides. 


296  EQUILIBRIUM  AND  VPTRTIGO 

IJi'oduces  no  vertigo  whatever  or  impaired  vertigo,  instead  of  assum- 
ing the  presence  of  a  great  many  lesions,  it  is  more  reasonable 
to  suppose  that  there  is  one  lesion  at  a  point  where  all  the  fibres 
concerned  in  vertigo  come  together.  Such  a  point  is  found  at  the 
decussation  of  the  superior  cerebellar  peduncles  where  all  of  the 
fibres  concerned  pass  from  the  cerebellum  on  their  way  to  the  cere- 
bral cortex.  Again,  given  a  case  with  no  responses  at  all  from 
stimulation  of  the  right  ear,  and  an  absence  of  responses  from  the 
vertical  canals  of  the  opposite  or  left  ear,  instead  of  assuming 
two  lesions — one  located  in  the  right  labyrinth,  cutting  off  all  the 
responses  from  that  side,  and  another  lesion  in  the  left  side  of  the 
pons — it  is  more  reasonable  to  explain  the  wdiole  phenomenon- 
complex  by  a  single  lesion  in  the  right  cerebello-pontile  angle,  wdiere 
an  involvement  of  the  right  VIII  Nerve  ^\dthin  this  lesion  would 
block  all  responses  from  the  right  labyrinth,  and  the  same  lesion 
by  pressure  against  the  brain-stem  would  interfere  with  the  re- 
sponses from  the  vertical  semicircular  canals  of  the  opposite  side. 
Just  as  in  Neurolog}"  a  certain  group  of  symptoms  occurring 
with  a  definite  lesion  are  spoken  of  as  the  "symptom-complex"  for 
that  lesion — in  the  same  way  a  constant  group  of  phenomena 
always  appearing  on  ear  stimulation  in  a  certain  lesion  may  be 
regarded  as  the  "phenomenon-complex"  for  that  particular  lesion. 
The  following  should  be  remembered : 

(1)  If  the  results  of  stimulation  of  the  right  ear  are:  Nystag- 
mus, none;  vertigo,  none;  past-pointing,  none;  falling,  none,  it 
obviously  indicates  a  destruction  of  the  right  labyrinth  or  VIII 
Nerve  (see  Fig.  97).  We  w^ould  of  course  have  the  corroborative 
evidence  of  complete  deafness  in  this  ear.  This  picture  of  a  dead 
auditory  apparatus  and  a  failure  of  any  of  the  semicircular  canals 
to  produce  responses,  shows  beyond  all  doubt  that  the  labyrinth  or 
VIII  Nerve  is  destroyed. 

(2)  If  stimulation  of  the  right  horizontal  canal  produces:  Nys- 
tagnms,  none;  vertigo,  normal;  past-pointing,  normal;  falling,  nor- 
mal; it  suggests  a  lesion  in  the  medulla  oblongata  between  Deiters' 
nucleus  and  the  posterior  longitudinal  bundle  on  the  right  side  (see 
Pig.  98). 


PATHOLOGIC  CASES  ANALYZED 


297 


(3)  If  stimulation  of  the  right  horizontal  canal  produces:  Nys- 
tagmus, normal;  vertigo,  none;  past-pointing,  none;  falling,  none; 
it  suggests  a  lesion  of  the  right  inferior  cerebellar  peduncle  (see 
Fig.  99). 


RIGHT 


LEFT 


Fig.    97.- — Dotted  lines  indicate  lesion. 


(4)  If  stimulation  of  the  right  vertical  canals  produces:  Nys- 
tagmus, none  ;  vertigo,  normal ;  past-pointing,  normal ;  falling,  nor- 
mal; it  suggests  a  lesion  in  the  posterior  portion  of  the  pons  near 
the  posterior  longitudinal  bundle  on  the  right  side  (see  Fig.  100). 

(5)  If  stimulation  of  the  right  vertical  canals  produces :  nystag- 


-298 


EQUILIBRIUM  AND  VERTIGO 


mus,  normal;  vertigo,  none;  past-pointing,  none;  falling,  none;  it 
suggests  a  lesion  of  the  right  middle  cerebellar  peduncle  (see 
Fig.  101). 


RIGHT 


LEFT 


TEMPORAL 
LOBE 


Fig.   98. — Arrow  point.s  to  lo.sion. 


(6)  If  stimulation  of  the  horizontal  canals  of  both  ears  and 
also  of  the  vertical  canals  of  both  ears  produces :  Nystagmus,  none ; 
vertigo,  normal ;  past-pointing,  normal ;  falling,  normal ;  it  suggests 
a  lesion  of  the  posterior  longitudinal  bundle  itself  (see  Fig.  102). 

(7)  If  stimulation  of  the  right  horizontal  canal  and  also  of 
the  right  vortical  canals  produces:  Nystagmus,  normal;  vertigo. 


PATHOLOGIC  CASES  ANALYZED 


299 


none;  past-pointing,  none;  falling,  none;  it  suggests  a  lesion  of 
the  cerebellar  vestibular  nuclei  of  the  right  side  (see  Fig.  103). 

(8)  If  stimulation  of  all  the  semicircular  canals  of  both  ears 
produces:  Nystagmus,  normal;  vertigo,  none;  past-pointing,  none; 

RIGHT  LEFT 


^/TEMPORAL 
LOBE 


piG.   99. — Arrow  points  to  lesion. 

falling,  none  ;  it  suggests  a  lesion  at  the  base  of  the  cerebral  crura  at 
the  point  of  decussation  of  the  two  superior  cerebellar  peduncles 
(see  Fig.  104). 

(9)  If  there  is  total  deafness  in  the  right  ear  and  stimulation 
of  the  right  horizontal  semicircular  canal  and  of  the  right  and  left 


300 


EQUILIBRIUM  AND  VERTIGO 


vertical  semicircular  canals  produces :  Nystagmus,  none ;  vertigo, 
none;  past-pointing,  none;  falling,  none;  and  stimulation  of  the 
left  horizontal  semicircular  canal  produces  normal  reactions,  the 
lesion  is  located  in  the  right  cerebello-pontile  angle  (see  Fig.  105). 


RIGHT 


LEFT 


TEMPORAL 
LOBE 


TEMPORAL 
LOBE 


Fig.    100. — Arrow  points  to  lesion. 


It  will  be  understood,  of  course,  that  actual  lesions  do  not  always 
fit  neatly  into  the  above  schemata.  As  in  medical  diagnosis  gener- 
ally, all  symptoms  must  be  considered  in  their  relation  to  other 
symptoms  and  that  lesion  postulated  which  will  best  explain  the 
completed  picture,  just  so  in  aural  examinations  relative  values 


PATHOLOGIC  CASES  ANALYZED 


301 


must  be  given  to  the  various  findings  before  a  conclusion  is  reached. 
A  lesion,  for  example,  may  involve  more  than  one  of  the  typical 
locations  given  in  the  charts,  say  the  cerebello-pontile  angle  and  the 
cerebellum  itself;  furthermore,  the  interference  with  the  normal 


RIGHT 


LEFT 


TEMPORAL 
L06E 


Fig.    101. — ^Arrow  points  to  lesion. 


TEMPORAL 
LOBt 


reactions  may  be  due  to  direct  destruction,  or  to  transmitted  pres- 
sure or  both.  Hence  diagnoses  cannot  be  made  by  rule  of  thumb, 
but  must  be  based  on  a  practical  analysis  of  all  the  findings. 

In  order  to  make  clear  the  method  of  analysis,  the  following 
cases  have  been  classified  according  to  the  site  of  the  lesion,  begin- 


30-2 


EQUILIBRIUM  AND  M:RiIGO 


ning-  with  the  middle  ear,  contiiming  to  the  internal  ear,  tlie  VII L 
Xerve,  the  medulla  oblongata,  the  pons,  cerebellum,  cerebrum  and 
cerebello-pontile  angle 

RIGHT  LEFT 


The  general  broad  division  consists  of 


Fig.  102. — Arrow  points  to  lesion. 


l^eripheral  and  central  lesions.  The  peripheral  lesions  include  those 
of  the  labyrinth  and  the  VIII  Nerve  while  the  central  lesions  include 
the  remainder  of  the  cases. 


Case  1. — Mr.  John  B.,  age  50.  This  case,  so  far  as  we  have  been  able  to 
ascertain,  is  the  first  demonstration  in  the  living  human  being  of  the  experiment 
which  Ewald  originally  perforated  on  pigeons.  _ 


PATHOLOGIC  CASES  ANALYZED 


303 


The  following  is  the  patient's  history  as  g-iven  in  his  own  words: 
"As  far  back  as  I  can  renieuibt-r,  I  have  had  a  running  ear.  j\ly  parents  told 
me  that  it  originally  came  from  an  atta<?k  of  scarlet  fever  when  a  child.  The 
discharge  was  not  constant.  It  would  appear  occasionally,  lasting  for  thi-ee  or 
four  months,  and  then  would  disappear  for  a  period  of  four  or  five  years.  In  June, 
191(),  the  ear  he^aii  to  have  this  discharue.  the  onlv  difference  being  tliat  a  little 
RI6HT  LEFT 


TEMPORAL 
LOBE 


Fig.    103. — .\irow  points  to  lesion. 


white  kernel  came  out.  This  looked  like  a  little  mass  of  maggots  without  life.  I 
merely  noticed  this  little  mass,  but  I  suffered  no  inconvenience,  and  thus  matters 
stood  until  the  beginning  of  August.  1916.  I  then  felt  a  slight  irritation  in  the 
outer  part  of  my  right  ear.  I  placed  my  finger  on  the  outside  and  rubbed  gently 
to  alleviate  this  irritation.  To  my  intense  surprise,  the  whole  room — everything 
in   sight,    in    fact — ^i-evolved    rapidly    from    the   left    to    the   right,    and    as    quickly 


304 


EQUILIBRIUM  AND  \  ERTIGO 


back  again.  Thinking  tlial  tliis  was  only  a  delusion.  I  tried  this  'push-button 
melbod'  several  times,  and  iioi  mu-e  did  it  fail  to  register  what  I  have  just  stated. 
I  am  a  railroad  conductm-.  ;iii(l  1  have  ti-ied  this  same  experiment  while  on  the 
train.  While  standing  on  I  ho  lear  ])latlonn  of  one  of  our  cars  I  rul)bed  my  ear 
and  the  entire  train  seemed  to  lea\e  the  track,  swing  over  to  the  right,  and  swing 


RIGHT 


LEFT 


104. — -Arrow  points  to  lesion 


back  again  quickly.  This  swinging  of  the  train,  first  to  the  right  and  tlicn  back  again, 
seemed  to  occur  with  myself  acting  as  the  axis  of  tlie  turning.  However,  I  paid 
no  more  attention  to  this  matter,  merely  making  it  a  point  to  keep  my  finger  away 
from  my  ear,  hoping  that  this  queer  condition  might  gradually  disappear.  A 
few  mornings  later,  however,  I  was  lying  in  bed  on  my  back,  and  as  I  rolled  over 
on  my  right  side,  it  seemed  as  tliough  some  giant  had  lifted  the  left  side  of  the 


PATHOLOGIC  CASES  ANALYZED 


305 


bed  to  turn  it  over  to  the  right,  on  top  of  me.  I  made  a  grab  for  the  bed- 
covers. By  this  time  I  had  stopped  turning  over  to  the  right,  and  the  elevating 
of  (he  bed  stopped  at  the  same  time.  I  must  confess  that  I  now  began  to  be  a 
little  bit  scared,  as  I  could  not  understand  why  these  things  should  be.  Sevei'al 
days  later,  while  on  duty,  I  was  addressed  by  a  passenger,  and  turned  quickly  to 


RIGHT 


LEFT 


TEMPORAL 
LOBE 


Fig.   105. — Arrow  points   to  lesion. 


the  right  to  answer  his  question,  when,  to  my  surprise,  I  found  myself  falling 
against  the  seats  on  the  left  side.  This  unsettled  condition  became  more  and  more 
intense  each  day,  until  it  got  so  bad  that  I  could  not  even  shake  my  head  from 
side  to  side,  in  saying  '  no  '  in  conversation,  without  having  this  '  falling  feeling' 
come  over  me.  I  now  became  thoroughly  frightened,  as  I  thought  these  symptoms 
must  surely  be  the  forewarning  of  paralysis.  I  therefore  consulted  our  family 
20 


300  EQUILIBRIUM  AND  VERTIGO 

physician,  Dr.  Victor  Janvier,  wlio  told  me  that  evidently  there  was  something 
serious  the  matter  with  my  ear.'" 

Ear  Examination.  Kight  ear  showed  exacerbation  of  a  chronic  purulent 
otitis  media,  with  a  large  perforation  in  the  upper  posterior  (juadrant.  No  polypi 
or  grannlation  tissue.  The  pus  was  thick,  creamy  and  fetid.  Thei-e  was  necrosis 
of  the  upper  posterior  portion  of  the  bony  tympanic  ring.  The  left  ear  showed 
evidence  of  a  healed  chronic  purulent  otitis  media.     Both  cochleas  were  normal. 

There  was  no  spontaneous  nystagmus  or  past-pointing.  Turning  to  the 
right  and  to  the  left  produced  distinctly  subnormal  nystagmus,  vertigo  and  past- 
pointing. 

Pressure  by  a  Politzer  bag  applied  to  the  right  auditory  meatus  caused  a 
pure  horizontal  nystagmus  to  the  right  and  a  systematized  vertigo  also  exclusively 
to  the  right.  This  could  have  been  produced  only  by  an  endolympli  movement 
exclusively  to  the  left.  The  eyes  were  drawn  to  the  left  in  the  direction  of  the 
endolymph  movement,  and  the  quick,  cerebral  jerk  to  the  right  completed  the 
nystagmus  to  the  right.  As  the  vertigo  is  always  in  a  direction  opposite  to  the 
endolymph  movement,  this  endolymph  n)ovement  exclusively  to  the  left  produced 
a  systematized  vertigo  to  the  right.  Because  of  this  systematized  vertigo,  all  of 
the  extremities  past-pointed  to  the  left  during  the  time  that  the  pressure  was 
applied  to  the  ear. 

The  accomi^anying  series  of  photographs  (Figs.  lOG  to  110)  shows  the 
patient's  ability  to  find  the  finger  spontaneously.  When  the  Politzer  bag,  ho\yever, 
is  compressed,  the  patient  is  unable  to  find  the  finger,  but  "past-points"  to  the  left 
witli  all  extremities. 

Comment 
It  is  a  matter  of  common  experience  that  in  a  certain  number 
of  cases  of  chronic  purulent  otitis  media  there  is  an  extension  of 
the  process  into  the  hil)yrinth,  whicli  is  made  evident  by  tlie  ap- 
pearance of  a  nystagmus  when  pressure  is  ap])lie(]  to  tlic  external 
auditory  meatus.  When  a  nysta,ij;-nius  ap])ears  on  pressure,  the 
fistula  test  is  considered  positive  and  usually  indicates  a  fistulous 
opeiiino-  into  the  labyrinth.  The  production  of  a  nystac^mus,  how- 
ever, proves  merely  that  there  is  present  an  openini*-  into  the  laby- 
rinth at  some  i)oint.  Tn  the  original  Ewald  experiment  an  arti- 
ficial plug  was  inserted  into  a  semicircular  canal  and  then  a  hole 
was  drilled  at  a  point  adjacent  to  this  plug.  In  this  way  Ewnld 
was  enabled  to  cause  an  endolymph  current  in  one  dirrcfion  only. 
This  patient  has  not  only  an  o])ening  into  his  horizontal  semi- 
circular canal,  located   at   the  point  where   the   canal  bends   out- 


PATHOLOGIC  CASES  ANALYZED 

Fir;      lOG.  f^IG.  107. 


307 


".9 


Fig.   106. — Pointing;  right  shoulder  from  above.         Fi<;.    107. — Pointing;  left  shoulder  from  above. 
Fig.   lOS.  Fig.   109.  Fig.  110. 


Fl(i.  108. —  Pointing;  elbow  Ironi  almw.  lie.    lU'.t.  —  Poinling;  right  hi|i  fruni  l)rlow. 

Fig.    110. — Pointing;  left  hip  from  below. 


308  EQUILIBRIUM  AND  VERTIGO 

ward  to  produce  the  aditus  ad  antrum,  l)ut  lie  also  has  a  closure 
of  the  canal  at  a  point  behind  the  fistulous  oi)ening-.  This  is  demon- 
strated by  the  fact  that  pressure  by  the  Politzer  bag  produces  not 
only  a  nystagmus  but  a  systematized  vertigo.  This  systematized 
vertigo  is  not  merely  made  probable  by  the  intelligent  statement 
of  the  patient  himself  that  he  feels  that  he  is  rotating  to  the  right 
at  a  speed  of  forty  miles  an  hour,  but  is  also  definitely  proven  in 
that  he  past-points  to  the  left  invariably,  with  all  extremities,  be- 
cause of  this  vertigo. 

Under  local  treatment  the  purulent  discharge  has  disappeared, 
the.  symptoms  have  subsided  and  the  fistula  test  is  no  longer 
positive. 

Case  2. — Mrs.  A.  G.,  age  44.  Patient  was  admitted  to  a  Philadelphia  hos- 
pital October  20,  1914,  with  the  following  history:  Was  in  good  health  until  three 
months  before  admission.  The  first  thing  noted  was  difficulty  in  walking;  this 
continued  for  one  month,  when  patient  began  to  notice  "trouble  with  the  ej^es." 
Fii'st  she  noticed  occasional  flashes  of  light  before  the  eyes  and  in  the  course  of 
two  weeks  more  she  realized  that  her  vision  Avas  getting  dim.  One  month  before 
admission  to  the  hosi^ital  she  began  to  have  attacks  of  vertigo,  nausea  and  pro- 
jectile vomiting,  associated  with  severe  occipital  headache.  The  difficulty  in 
walking  has  steadily  increased,  with  a  tendency  to  falling — always  to  the  right  side. 
She  had  never  had  a  convulsion. 

The  record  of  the  physical  examination  is  as  follows:  "No  tremor  of  ex- 
tremities but  slight  ataxia  of  both  amis  and  legs  and  slight  hypermetry  of  the 
right  upper  extremity.  Romberg — falls  to  the  right.  Can  not  stand  on  either 
foot;  falls  to  the  right.  Delayed  sensation,  particularly  on  the  right  side  of  the 
body,  and  numbness  on  the  dorsum  of  the  right  hand.  The  right  pupil  is  slightly 
larger  than  the  left  and  there  is  a  slight  drooping  of  the  left  eye-lid." 

The  patient  had  been  sent  to  the  hospital  with  a  provisional  diagnosis  of 
brain  tumor;  this  diagnosis  was  confirmed  by  the  internists  at  the  hospital  and 
two  neurologic  consultants  agreed  that  the  histoi"y,  symptoms  and  examination  in- 
dicated a  tumor  of  the  right  cerebellar  hemisphere.  This  diagnosis  was  further 
confirmed  by  the  X-ray  report,  which  stated  that  the  photographs  showed  a  tumor 
in  the  right  cerebellar  hemisphere  and  that  it  appeared  to  be  a  cyst.  All  agreed  that 
operation  was  indicated. 

It  was  at  this  time  that  the  ear  examination  was  made.  It  is  of  peculiar  in- 
terest to  note  that  the  reason  an  ear  examination  was  suggested  was  not  because 
any  particular  help  was  expected  in  making  the  diagnosis,  but  because  of  the 
unusual  opportunity  to  determine  what  the  ear  tests  would  show  in  a  case  in 
which  the  diagnosis  was  already  so  clear  and  definite. 

Ear  Examination.     Referring  to  the  chart    (XV),   we   note  particularly  that 


PATHOLOGIC  CASES  ANALYZED  309 

the  past-2Jointing  of  both  arms  in  both  directions  was  not  only  present  and  in  the 
correct  direction,  but  that  the  past-pointing  was  even  exaggerated  in  its  extent. 
The  lower  exrreniities  also  past-pointed  correctly  in  both  directions.  This  exag- 
gerated past-pointing  in  the  correct  directions  was  observed  both  after  turning 
and  douching. 

Because  of  the  newness  of  this  type  of  examination,  the  following  report 
was  made  with  considerable  misgiving:  "The  ear-tests,  per  se,  would  suggest  that 
the  cerebellum  is  normal.  The  pointing  tests  of  the  upper  and  lower  extremities 
after  stimulation  of  the  labyrintbs  would  seem  to  indicate  normal  cerebellar  hemi- 
spheres; the  tests  for  the  neck  and  trunk  also  show  normal  resjionses,  which  sug- 
gests that  the  vermis  is  normal." 

Because  of  the  ear  report,  operation  was  postponed  to  await  developments. 
The  patient  soon  began  to  get  better  and  better,  was  discharged  from  the  hospital 
within  a  month,  has  since  given  birth  to  a  healthy  child  and  has  remained  in  good 
health — at  least  up  to  the  last  time  she  was  seen,  which  was  nearly  tAvo  years 
after  her  illness.  As  she  has  moved  to  another  city,  we  do  not  know  her  present 
condition. 

Because  of  the  happy  outcome  in  this  case,  the  actual  nature  of  the  lesion  is 
not  determined.  However,  the  case  serves  to  illustrate  how  the  ear  tests  may  be 
of  value  in  preventing  unnecessary  operations. 

Case  3. — Mrs.  W.  B.  W.,  age  51.  Chief  complaint,  attacks  of  vertigo  and 
staggering,  impaired  hearing  and  slight  tinnitus. 

Referred  on  February  4,  lOlG,  with  the  following  history :  First  attack  of 
dizziness  in  1897,  lasting  three  minutes;  she  had  three  or  four  attacks  shortly  after 
that — approximately  one  every  month.  One  attack  in  1911  was  quite  severe,  with 
considerable  nausea,  and  lasted  24  hours.  Two  months  later  another  attack  occun-ed 
while  on  the  street,  but  she  was  able  to  get  home  and  the  symptoms  disappeared 
after  three  hours.  In  June,  1913,  a  slight  attack,  lasting  ten  minutes.  In  August, 
1913,  a  more  severe  attack  with  nausea  lasting  48  hours.  In  August,  1914,  an 
attack  of  48  houi-s'  duration,  with  continued  vertigo  and  nausea,  and  for  one  week 
patient  was  unable  to  retain  anything  in  her  stomach — not  even  a  glass  of  water. 
For  the  next  six  months  there  were  repeated  attacks  every  month  or  so,  each  lasting 
four  or  five  hours,  usually  with  nausea. 

In  December,  1914.  because  of  nausea,  vomiting,  emaciation  and  jaundice,  an 
operation  on  the  gall,  bladder  was  performed,  malignancy  having  been  suspected. 
The  g'all  bladder  Avas  found  to  be  normal.  The  attacks  continued  with  more  or  less 
frecpiency — one  attack  occurring  three  weeks  after  the  operation.  November,  1915, 
while  sitting  in  the  theatre,  patient  was  seized  with  a  severe  attack  of  dizziness, 
nausea  and  vomiting,  and  had  to  be  taken  from  the  theatre  to  the  hospital,  where 
she  was  confined  to  bed  for  seven  days. 

First  noticed  impairment  of  hearing  in  1903.  In  1911  deafness  in  the  left  ear 
became  more  noticeable  and  after  the  severe  attack  in  November,  1915,  she  noticed 
that  she  Vv'as  entirely  deaf  in  the  left  ear.  Patient  had  complained  of  noises  in  the 
head  occasionally  during  the  past  ten  years.  After  the  attack  in  1915  the  noises 
have  been  louder;  they  are  not  continuous,  however,  and  are  only  in  the  left  ear. 


310 


EQUILIBRII^M  AND  VERTIGO 


Address 

Referred  by 


CHART  XV  A 

(Vge    -^^  Date   ^l^-  6. /^  '  "^ 


DUGNOSIS: 


SUMMARY: 


Complains  of 


HISTORY.  o 

Dizziness     ^i/^ 
Staggering    fy.,c^ 
Deafness       "Ho 
Tinnitus        K» 


^.<*-0->VCCC«^*^<^ 


NOSE:  fo   Ayl-ffvtx-C.      Xl.C-,yu^tAjtZ<. 

THROAT:     (y^^Z<LAl^  «,t<^.«.A«     >ci^  i(a^*^lo^<^  .     Pf^vt^    o-^a.*^ 


EARS: 


A.  D.  JjU^^^^o^ 


'.^     /< 


A.  s.  v/*«^a,oi^  ^i^^^A^^^l^x::^  />4. 


Fistula      t^e^  tiXZ<rt. 
Hearing  Tests 


3  iaji^t.An-^*- 
Ac      >      Be    «:      n  Pol. 

Ac     >      Be    <<;      II 


<_.4  I  t?»*^       Gait  I  .  ^  


PATHOLOGIC  CASES  ANALYZED 


311 


CHART  XV  R 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT     ^ 
Looking  to  LEFT     i^ 
Looking  UP      ^l^t  i/ 
Looking  DOWN    yj^vU, 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 

3  ■■  Z  -^^u 


t^titXAMt^   jtaiXi*^ 


Nystagmus 

Vertigo     ^^<^ 

Past-pointing    H-\^^ 

Falling    ll^     Zi   'R.CtCc    ->-^  Wc«^  */t*i<. 
Romberg     /«z/»/  Xi  'R-Cj^ 
Turning  head  to  right     >.«^  Xi-JZ^ 
Turning  head  to  left       -t-.^   jtjt.^Zi^ 
Attempt  to  overthrow    (jlijiX^j.*^ 


LEFT 


To  RIGHT       >. 

Amp.    ^i»-r-^ 
Duration  VoSec. 


To  LEFT     < 

Amp.     3«4-c/ 
Duration  3  S  Sec. 


TURNING 

To  RIGHT 

Shoulder  from  above 


Nystagmus    i^a^acit^oXl^ 
Vertigo     i/ii^o^  qyJL^XZfl 
Past-pointing    L^a^it  qiA.a/2^ 

^^H^     fpr^rv**-    U'\jL*y^ 


To  LEFT 
Shoulder  from  above 


Nystagmus    i^'iM^ni^^t/UL 
Vertigo     t^oy^vi^otty 
Past-pointing    \^o~aa,i:i,oMJL 


/*"  toT^.^X^-Ato  Tfx^ttr 

I 

/5-    to/t^     ^-tn    jC^ 


V-  :£.  ^\^ 


.^-  t,  ^si4. 


Douche  RIGHT     ^^ 

Amp.       fj  <r-<r-^ 

After        min.<f<rsec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  .^♦'Vw-^ 
Vertigo     ^.vv-u.^ 
Past-pointing    <t«^a-«  o  t/t-o^G^ 
Falling    Jt,^^''" 


Head  Back    Ji^U.  tUXUL 

Amp. 

Douche  LEFT     n 

Douche  LEFT 

Amp.  ^^^aIAx 

Shoulder  from  above 

After    /    min.  tTJ'sec. 

1 

Nystagmus 

Vertigo 

Past-pointing 

Falling 

Head  Back    X*^  ituXiU. 

Amp- 

IX-  i^;^U-^'ioT(^^' 


/S-  to^e^  «5"'to  V^" 


312  EQUILIBRIUM  AND  VERTIGO 


CHART  XVI  A 


Name    -<^^.  ^   '^  '^  Age  cTi  Date '^C^  V ,  ^'fiC 

Referred  by     ^a- J'^t.t^yU    iHiZjLX^ . 


Address 


DIAGNOSIS: 


SUMMARY: 


Complains  of     '^XZeie^i.    ,*/     M~\XZZa  g-      Xrr    >V  ( 


HISTORY: 

Dizziness      i^c-a-- 
Staggering     i'-oor 
Deafness      ^^i^     -^^*^    C<»-->' 
Tinnitus       ^<^^    ^^^  '^*^ 


NOSE:     ST-tytxl^    ^y6ut^  vc^-c^    '^'^    y^'^eUU^   lujutM,.^ 
THROAT:     ^-^^  .aZZ.^ 


Fistula     '^-e^  dX^v-l, 


Hearing  TesU  S'TvC-<^ 

k\3/^        l'^\1  Ac    >      Be    =       n  Pol.  I  —  c«  I '5'-^        Gait  I  «>T  3  

~lo  lo  AcPBc<d  1—  I  '/'^^  I  }7«^ 


PATHOLOGIC  CASES  ANALYZf:D 


313 


CHART  XVI  B 


NYSTAGMUS 
Looking  to  RIGHT     ~r.ru. 
lx)oking  to  LEFT    c/A>k^. 
Looking  UP      Jf^n^ 
Looking  DOWN    Jr.tr.'^ 


1  ESTS  OF  THE  VES'ITBULAR  APPARATUS 
SPONTANEOIS 


Shoulder  from  above 


Nystagmus 

Vertigo 

Past-pointing 

Falling 

Romberg 

Turning  head  to  right 
Turning  head  to  left 
Attempt  fo  overthrow 


POLNTLVG 


RIGHT 


LEFT 


To  RIGHT     - — 5. 

Amp.    ^^xyOt^XJioiJuj 

Duration    ?  Sec. 


ToLEFP     < 

Amp.  Ti-fJZi^  LaJ~  /,(, 
Duration   >o  Sec 


TURNING 


To  RIGHT 

Shoulder  from  above 


/  "    to7^//fi-       f5;ia-£»-«t 


Nystagmu.s    '«^£^^'«-<»'i^ 
Vertigo 
Past-pointing       •• 


To  LEFT 

Shoulder  from  above 

Nystagmu.s  A/K.yiU^,..^     L>yf-    l/-,XCIl,.^^ 

Vertigo 
Past-pointing         _, 


/;?"to-(^ 


'U^  X^=^ 


'^^li-.-'f^i  (<r^,a^^ 


Douche  RIGHT     ^^ 
Amp.   ofw^^yXt 
After   3.  min   3o  sec 


Head  Back    — ^• 

Amp.      >/^i-crTr 

Douche  LEFT     ^^ 

Amp.   ^/Lco/Jr 
After   •?    mln.y3sec 


Head  Back 
Amp.  6?^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus    rv^-u^i i^tLLu   i.c*^c<-€/L4.^ 

Vertigo      /5/7-t<^..^*-<^ 

Past-pointing    ^/r^xiXw^ 

Falling    <Lt...^-K,.^v*xx.^     t,.-^  ^juyojuuJ- 


I     Douche  LEFP 

ij     Shoulder  from  above 

Nystagmus    >M_tiA'«.^-^'^^   -co.»^,«..<^i--c^ 

Vertigo     /)/r<yiJUU         ^ 

Past-pointing    ^  rt^^ji,^ 

Falling     ^u..^^.^^^,^^     (i:,^    I^^j^u.^ 


S-\oT^^ix  V"to  ^^-<1^ 
.J'  to>^v^  v^'to,^^ 

J'to>(J^  3  "tn  A^ 


314 


EQUILIBRIUM  AND  VERTIGO 


Ear  Examiiiation. — Referring  to   the   chart    (XVI).   we   note   impairment   in 
nystagmus,  vertiero.  past-pointing  and  falling  after  tuniing  and  douchins'. 
The  following  report  was  made  : 


RIGHT 


LEFT 


TEMPORAL 
LOBE 


Fig.   111. — Dotted  lines  indicate  location  of  the  lesion. 

Right  ear:  (1)  Cochlea  nonnal,  for  all  practical  purposes:  there  Ls,  however,  a 
■distinct  impairment  for  the  verj-  highest  tones.  This  suggests  that  there  has  been 
a  disturbance  in  the  cochlea  which  has  cleared  up.  (2)  Static  labyrinth.  Distinct 
impairment  of  the  horizontal  and  also  the  vertical  semicircular  canals. 

Left  ear:  (1)  Cochlea  "stone  dead."  (2)  Static  labyrinth.  Marked  impair- 
ment of  the  vertical  semicircular  canals.  Moderate  impairment  of  the  horizontal 
semicircular  canal. 


PATHOLOGIC  CASES  ANALYZED  315 

Conclusions. — The  attacks  have  been  caused  by  a  toxic  process  in  both  internal 
ears  (Fig.  111). 

Prognosis. — "For  ultimate  I'ecovei-y,  prognosis  is  very  good.  She  will,  how- 
ever, have  other  attacks  unless  the  source  of  the  toxaemia  can  be  found.  A  mere 
congestion  of  ischemia  of  the  labyrinth  would  hardly  account  for  the  definite  degen- 
eration that  has  taken  j^lace  in  the  labyrinths." 

Her  physician  considers  that  the  toxaemia  which  caused  the  labyrinthitis  was 
of  intestinal  origin,  and  he  noticed  that  whenever  she  ate  eggs  or  fish  she  almost 
invariably  had  vestibular  symptoms.  Indicanurea  was  frequently  demonstrable. 
Under  dietetic  treatment  the  patient  has  impi'oved,  and  for  the  past  year,  to  date, 
has  been  free  from  any  attacks. 

Case  4. — Mr.  D.  L.  V.,  age  32.  Chief  complaint — tinnitus,  impaired  hearing, 
vertigo  and  staggering.    Referred  by  Dr.  Alfred  Stengel  with  the  following  history : 

While  at  the  Plattsburg  Training  Camp  on  October  1,  1916,  patient  was  some- 
what stunned  by  the  explosion  of  a  rifle  near  his  left  ear.  Thirteen  days  later  he 
began  to  be  dizzy.  This  vertigo  was  constant  for  two  weeks,  but  after  that  was 
noticeable  only  when  standing  or  walking.  When  he  lay  down  he  noticed  no  "swim- 
ming of  the  head,"  but  a  slight  sensation  of  nausea,  similar  to  that  of  seasickness. 
Staggering  was  quite  marked  for  the  first  two  weeks  and  was  more  noticeable  in  the 
dark.  At  the  time  of  the  attack,  October  13th,  patient  also  noticed  sudden  impair- 
ment of  hearing  and  noises  in  the  left  ear,  similar  to  the  rapid  ringing  of  a  small 
shrill  bell  at  a  considerable  distance. 

Ear  Examination. — Referring  to  the  chart  (XVII)  we  note  that  the  hearing 
tests  are  suggestive  of  the  very  slightest  nerve  impairment  of  both  ears.  Patient 
has  himself  obsel■^•ed  that  the  recent  impairment  of  hearing  in  the  left  ear  has 
largely  disapi^eared.  Turning  and  douching  show  markedly  impaired  nystagmus, 
vertigo,  past-pointing  and  falling — in  other  words  all  responses  from  both  ears  are 
impaired. 

The  following  report  was  made — "Summary — Impairment  of  both  internal  ears 
(Fig.  112),  especially  the  left.    In  detail: 

(1)  Right  ear.  (a)  Cochlea  normal,  except  in  its  uppermost  register,  which  is 
impaired,  (b)  Semicircular  canals  distinctly  subnormal.  The  vertical  canals  are 
impaired  1/3  of  nonnal  function ;  horizontal  canal  shows  similar  impairment. 

(2)  Left  ear.  (a)  Cochlea  normal  except  for  the  very  highest  tones;  these 
upper  tones  are  somewhat  more  impaired  than  in  the  right  cochlea,  (h)  Semi- 
circular canals  almost  completely  destroyed.  The  vertical  canals  show  merely  a 
trace  of  function  and  the  hoiizontal  canal  is  completely  dead. 

Etiology. — The  definite  histoiy  of  noticeable  freedom  from  seasickness  all  his 
life  suggests  that  this  impairment  of  his  internal  ears  occurred  when  he  was  a  child. 
It  may  have  been  caused  by  mumps.  The  recent  attack  on  October  13th,  causing 
deafness,  tinnitus,  vertigo  and  staggering,  was  due  to  additional  involvement  of 
the  left  ear  only.  The  explosion  of  the  rifie  may  have  caused  a  concussion  of  the 
left  internal  ear,  but  it  must  be  noted  that  the  tinnitus  and  vertigo  did  not  occur 
immediately  after  the  explosion. 

Prognosis. —  (1)  Hearing — good  prognosis.  The  recent  impairment  of  hearing 
in  the  left  ear  has  cleared  up  very  noticeably  in  the  past  two  weeks;  this  shows  that 


316  EQUILIBRIUM  AND  VERTIGO 


CHART  XVII  A 


Name 

Address 


^^.'Zb.ty  Age   dZ  Date  ^-^  "'  '?  ^^ 

Referred  by   ^^    JljLjfy^U-    SXi^>^<4A^ 


DIAGNOSIS: 


SUMMARY: 


Complains  of    ^--fctZc^^^   .ia,^o<<6  y2-     ''/-oc^^i-ix,^  lAM^cjtAXi,.^  .*^    ■j£c*»*^j,^. 


HISTORY:  „ 

Dizziness      C'ce^ 
Staggering     Jz-v^o^ 
Deafness    ^JLC^JJ..    -■^^ 
Tinnitus    cS/L/u,  jUf^ 


NOSE:      '^jU'a-lA    -«:2>^  <i^    yMWu-c^u^ 

THROAT:     JHjt^-l-  .OAytAi-ct    p^^^Xc        '^JaXz^   ^  //»* 

EARS:  f  "  ■  '^ 

Fbtula       v^^    -XeyCCuiL 

Hearing  Tests  4_^        n  u\  /  9 

Al:t         Al/  Ac     >      Be     =     n  Pol.  cM|-^      Gait  ^  >^  _^^ 


PATHOLOGIC  CASES  ANALYZED 


317 


CHART  XVII  B 


TESTS  OF  THE  VESTIBULAK  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT     -^Av^ 
Looking  to  LEFT    Jf^ry^^ 
Looking  UP      w!«-w<. 
Looking  DOWN    Jo"^^ 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus 
Vertigo      •A'.r^dt, 
Past-pointing      *^>r«^ 
Falling      Jk,*^^ 

Romberg      TuuatJd/u-i^  . 

Turning  head  to  right     ^t-^^  aA^x. 

Turning  head  to  left       )\jt^AZZ\^^ 

Attempt  to  overthrow    >v»^UL*c«tZ  V^t.^M<-c 


LEFT 


To  RIGHT    > 

Amp.  Vi-a-r 
Duration   A.,  Sec. 


To  LEFT 


TURNING 


To  RIGHT 

Shoulder  from  above 


<^«U^ 


Amp.   P**-,. 
Duration    y  Sec. 


Nystagmus  prr-t^^ZCie-cUyUi 
Vertigo    >i.«-v*^  '>r&.aj(Xjli^ 
Past-pointing  <3-^«-»»^ 


To  LEFT 
Shoulder  from  above 


Nystagmus    <vt««->.-»-«> 

Vertigo  ,   /a.t<^6->^.<»A«/M-«.A 

Past-pointing  ^^^^,^   XiS    Xt.c..U    ^- exi-^C^v*, 


>'-^5<.'«-^*^ 


^  '■  xojCi^    <7^^UZc.0C 


Douche  RIGHT     /^ 

Amp.  '^5^1^ 

After    /   min.  3l  3  sec. 


Head  Back    - 
Amp.  ^^^^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


^"tolf.^di.  /"io-J^C^^ 


Nystagmus    /«**-»-*<-»^<*<-«-o 
Vertigo      /Xc./t'^<.'*-t,>**-A£ 
Past-pointing    ,4.c..^^-vva/u~«-i« 


Douche  LEFT    ^O  j     Douche  LEFT 

Amp.  -A?<k-MiL  ijw^fAJXtJytt.     [      Shoulder  from  above 
After  a,  min.  .S'^  sec.  j| 

Nystagmus     tLC<,,^i^<r^ 
Vertigo 

Past-pointing         ., 
Falling       d/>-\jtAAJ- 
Head  Back 


W^::jdju 


Amp. 


■>>y  4Z<a-J ->»*.«,<.<• 


^LlK^KycAjt^ 


SI  8 


EQUILIBRIUM  AND  VERTIGO 


there  was  either  a  concussion  or  mild  toxaemia  of  the  cochlea.  (2)  Vertigo — prog- 
nosis also  good.  The  cerebrum  should  very  readily  adapt  itself  to  this  ear  impair- 
ment, and  it  is  probable  tlint  within  a  month  the  patient  should  be  free  from  all 
dizziness  and  inco-ordinalidii. 


RIGH" 


LEFT 


Fig.   112. — Dotted  lines  indicate  location  of  lesion. 

Thi.s  opinion  was  justified  by  the  outcome  of  the  case — complete  recovery  from 
all  symptoms. 

Case  5. — Dr.  C.  W..  age  5.3.  Chief  complaint,  continual  tinnitus.  Referred  1  y 
Dr.  William  Gerry  Morgan  with  the  following  history: 

Patient  noticed  noises  in  the  head  during  the  winter  and  sprim:  of  lilOi).     In  the 


PATHOLOGIC  CASES  ANALYZED  319 

fall  of  1909,  while  on  board  a  vessel  crossing  from  Korea  to  Japan,  he  was  seized 
with  what  he  thought  to  be  seasickness.  The  vertigo,  however,  persisted  for  two 
weeks.  It  is  to  be  noted  also  that  the  tinnitus  was  increased  at  the  time  of  this 
attack.  Vertigo  and  unsteadiness  of  gait  disapi)eared  after  the  two  weeks,  but  the 
tinnitus  has  continued  to  the  present  date,  March  30,  1917.  In  1911,  while  in  South 
America,  for  two  months  patient  was  constantly  annoyed  with  a  sensation  that  he 
wanted  to  go  to  the  toilet,  and  yet  there  was  very  little  actual  diarrhoea.  He  at- 
tributed this  to  climatic  change. 

Ear  Examination. — Referring  to  the  accompanying  chart  (XVIII),  we  note 
that  the  tuning-fork  tests  show^  impaired  hearing  of  the  nerve  type,  and  the  nys- 
tagmus, vertigo,  past-pointing  and  falling,  after  both  turning  and  douching,  are 
impaired.     These  findings  may  be  summed  up  as  follows : 

(1)  Right  Ear.  (a)  Cochlea  shows  one  half  of  normal  function,  (b)  Ves- 
tibular labyrinth.  (r)  Horizontal  canal  slightly  impaired,  (v)  Vertical  canals 
slightly  imi^aired. 

(2)  Left  Ear.  (a)  Cochlea  impaired  one-tliird  of  normal  function.  (&)  Ves- 
tibular labyrinth,  (x)  Horizontal  canal  slightly  impaired  a  little  less  than  the  right 
horizontal  canal.      (//)  Vertical  canals  very  slightly  impaired. 

The  following  report  was  made:  "The  proportionate  impairment  in  both  ears 
of  both  the  cochlear  and  vestibular  portions  indicates,  first,  that  some  general  dis- 
turbance such  as  a  toxaemia  has  affected  both  portions  of  both  internal  ears  (Fig. 
113),  and,  second,  that  the  intracranial  pathways  from  the  ear  are  intact  throughout 
their  course  through  the  brain-stem,  cerebellum  and  cerebrum.  The  impairment  of 
the  vestibular  portion  of  each  internal  ear  is  in  no  sense  a  practical  drawback  to 
his  general  well-being.  The  tests  by  turning,  douching  and  the  galvanic  current  all 
agree  in  that  each  type  of  stimulation  produces  subnormal  responses  in  nystagmus, 
vertigo,  past-pointing  and  falling.  This  impairment,  however,  is  very  slight  and 
does  not  in  any  way  affect  his  equilibrium.  The  cause  of  the  original  attack  was 
most  probably  not  seasickness,  but  a  toxic  labyrinthitis  involving  both  internal 
ears.  This  internal  ear  disturbance  had  ai^parently  begun  in  slight  degree  the 
previous  winter  and  spring,  and  was  evidenced  by  the  tinnitus  which  began  at  that 
time.  The  peculiar  sensations  noticed  in  South  America  were  probably  not  climatic, 
but  due  to  the  toxic  irritation  of  the  internal  ears. 

Prognosis. — Excellent  for  hearing,  guarded  for  the  cessation  of  the  tinnitus. 
There  is  no  reason  to  anticipate  any  increase  in  the  impairment  of  hearing.  We 
are  not  dealing  w'ith  a  progressive  condition ;  the  mischief  was  done  nine  years  ago, 
once  and  for  all.  Similarly  w^e  need  have  no  fear  that  the  noises  will  increase  in 
severity,  and  it  may  reassure  the  patient  to  tell  him  this.  The  prognosis,  therefore, 
is  very  favorable,  Avith  tlie  single  exception  that  the  slight  tinnitus  which  he  now 
observes  when  he  is  in  a  very  quiet  place  or  when  he  is  physically  fatigued  will  in 
all  probability  continue." 

The  essential  point  in  this  case  is  that  the  vestibular  tests  Avere  helpful  in 
rounding  out  the  knowledge  of  the  cause  of  the  tinnitus  by  furnishing  an  additional 
method  of  approach  in  investigating  the  condition  of  the  labyrinths. 

Case  6. — Mr.  James  H.,  age  38.  Referred  by  Dr.  Charles  H.  Frazier  on  Janu- 
ary 7,  1916,  Avith  the  folloAving  history:  On  January  25th.  1913.  patient  was  oper- 


EQUILIBRIUM  AND  VERTIGO 


320 

CHART  XVI II  A 


Name    -t'<''  •     \U'   " 
DIAGNOSIS: 

SLTVDkL\IlY: 


Complains  of 


yy  jL'V^^MXZly^ 


HISTORY: 

Dizziness  •/To 

Staggering  ^ 

Deafness  tA'o 

Tinnitus  if^^Oy 


NOSE:     ^AA*^  ftJL.JjC^    .iCCUJ3-Lc.   ^,,,JZuAyJ<J. 

THROAT:  ^Z^^^^uJi,  'L^.^XJ.      J^^-U  .....— w^-   ny^.^^^^    a..oJ^^Z<U  ^   ^ fU^    ^  A^lcr. 

Fistula    ~yrji^/^CZ>yu-t. 

HearingTesU  ^  >.     . ''f^  Poll  cM  ^^-^        Gait  1  •  /        ^^^^^^ 

A I  '//         A I  ^  Ac     >     Be    <      n  Pol.    -  M  ^      .  /  V 

=  17  l<r  Ae     >      Be     <       n  I-  l9i-^  '/•/ 


PATHOLOGIC  CASES  ANALYZED 


321 


CHART  XVIII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT     yh^ry^ 
Looking  to  LEFT   Jf* 


'^r^ 


Looking  UP 


Looking  DOWN 


SPONTANEOUS 


Shoulder  from  above 


Nystagmus     X.e-l^^ 

Vertigo       >t.<rM^ 

Past-pointing       "K-e-v^-t, 

Falling     -n^e-k.»-t 

Romberg      ^  -^  iZZv-c 
Turning  head  to  right     h^Vj  aXCv-c 
Turning  head  to  left         7i^^^a.ZZv-c 
Attempt  to  overthrow         n.d^  ajC<M-i, 


POINTING 


RIGHT 


LEFT 


To  RIGHT    — > 

Amp.    5(^,_^   ti   f"^^ 
Duration    /a  Sec. 


To  LEFT 

Amp.  ^t-t-d  -A   Z"' 
Duration  Ji'Sec. 


??«^ 


"^ 


A*.t»  >^ 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus  CA^x^xxxa^  ^ 

Vertigo  J,^e,..jJ^  -   /  3  tu.<unK^to. 

Past-pointing    ei'^^cwvk^ 


To  LEFT 
Shoulder  from  above 


Nystagmus  C^^-^-iZu   .t**^<w/K-*^ 


Vertigo    cJ>^ 


-t<^^«,tA^-</  -  /^  AA<Vm-«6< 


Past-pointing   J'/^/zJi^  .^^^cMvtJ. 


Douche  RIGHT     ^^ 
Amp.  'V»-o-^ 
After    /   min.  ^o  sec. 


Head  Back    — ^ 
Amp.    Vo-o-/. 

Douche  LEFT     /^ 

Amp.    yo-»-<t 

^/I'f/'i    After    /  min    /o  sec. 


Head  Back    -^ — 
Amp.    ^t^tf 
21 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


^"  ^.o1^^U 


Nystagmus    ^i^^yt^ 
Vertigo  j/^/kZIu   ^l<.<x&- 
Past-pointing    S-k„u^y„J^ 
Falling   ^jU-.JcC^ 


Douche  LEFl' 
Shoulder  from  above 


Nystagmus   ^l^^Z/^   XUmU- 
Vertigo  ■■  •' 

Past-pointing    J'^•^v4c^y    fl..4Xiv..u«.*Z 
Failing      S..J..JL^ 


y  "toT^iW^ 


cr"to7^.,/Lf-V'to:;ft;j^- 
f^"  to>(^    <^'to    ^ 


i/"  to^ 


6 "to  >f^ 


322 


EQUILIBRIUM  AND  VERTIGO 


ated  on  at  the  hospital  of  the  University  of  Pennsylvania  for  persistent  tinnitus 
folloAving  a  fracture  at  the  base  of  the  skull.  Doctor  Frazier  divided  the  left  YIII 
Nerve  in  the  postei'ior  fossa.  Shortly  after  the  operation  all  the  roarin^f  and 
ringing  almost  entirely  disappeared.  After  the  patient  had  enjoyed  freedom  from 
symptoms  for  four  months,  however,  the  tinnitus  returned. 


RIGHT 


LEFT 


^   ./ 


Fig.    113. — Dotted  lines  indicate  location  of  lesion. 


Referring  to  the  chart  (XIX),  we  note  that  this  ear-examination  was  made 
three  years  after  the  operation.  The  findings  indicate  a  completely  non-function- 
ating left  ear,  for  the  following  reasons: 

(1)  The  tuning-fork  tests  show  complete  deafness  in  the  left  ear. 

(2)  Douching  the  left  ear  fails  to  produce  any  of  the  responses  in  nystagmus, 
vertigo,  past-pointing  and  falling. 


PATHOLOGIC  CASES  ANALYZED  323 

(3)  Turning  to  the  right,  which  stimulates  chiefly  the  left  ear,  causes  a  very 
poor  nystagmus,  vertigo  and  past-pointing,  whereas  turning  to  tlie  left,  which 
stimulates  particularly  the  right  ear,  shows  fairly  good  resijonses. 

This  examination  indicates  that  the  operation  not  only  completely  severed  the 
VIII  Neiwe,  but  there  has  been  no  regeneration  eitiier  of  its  cochlear  or  vestibular 
portions.  This  case  is  of  interest  in  that  it  may  throw  light  upon  some  phases  of 
the  subject  of  tinnitus.  At  first  glance  it  would  seem  to  bear  out  the  contention  of 
♦^hose  who  maintain  that  tinnitus  is  caused  by  a  lesion  within  the  labyrinth.  For 
four  months  after  the  severing  of  the  YIII  Nerve  the  patient  was  comparatively 
free  from  noises  in  the  head.  The  recurrence  of  the  tinnitus,  however,  shows  with- 
out question  that  in  this  case  at  least  there  occurred  after  the  severing  of  the  VIII 
Nerve  a  further  degenerative  process,  central  to  the  point  of  section,  and  capable 
of  producing  tinnitus.  Before  operation  it  would  seem  reasonable  to  consider  that 
the  process  attacked  the  cells  within  the  spiral  ganglia  peripheral  to  the  point  of 
section.  This  would  account  for  the  patient's  temporary  recovery  from  the  tinnitus. 
The  ear-tests  now  show  that  the  YIII  Ner^e  Avas  completely  severed,  and  yet  the 
tinnitus  recurred.  This  would  indicate  tliat  the  tinnitus  is  most  probably  produced 
by  a  further  toxic  involvement  of  the  ganglionic  cells  along  the  course  of  the 
auditory  nerve-tracts  or  at  their  tennini  in  the  cerebral  cortex. 

Case  7. — Charles  W.  C.  age  21.  gave  the  following  historj' :  About  two  years 
ago  while  a  sailor  on  board  a  United  States  battleship,  he  fell  from  the  upper 
bridge,  a  distance  of  ap^^roximateiy  40  feet,  first  striking  the  back  of  his  head  and 
then  the  right  side.  The  fall  rendered  him  unconscious  for  6  days  and  8  hours 
and  produced  severe  contusions  of  his  mouth,  nose  and  ears.  When  he  recovered 
consciousness  he  found  that  he  was  absolutely  deaf.  When  he  felt  strong  enough 
to  get  out  of  bed  he  discovered  that  he  could  not  walk  at  all  because  of  severe  vertigo. 
This  dizziness  persisted  until  two  months  ago,  w^hen  it  almost  completelj'^  left  him. 
Following  the  accident  he  lost  his  sense  of  smell  and  had  a  partial  loss  of  taste. 
About  two  months  after  the  accident  the  patient  thinks  that  he  recovered  some  of 
his  hearing  in  the  left  ear.  He  could  then  understand  shouted  words.  This,  how- 
ever, lasted  only  a  couple  of  weeks,  when  he  again  became  totally  deaf.  A  year 
and  a  half  after  the  accident  he  was  discharged  from  the  Navy  and  soon  after  that 
noticed  that  he  was  regaining  some  of  his  hearing.  At  the  present  time  the  patient 
says  he  can  distinguish  high  or  low  tones  on  the  piano  and  can  hear  the  door-bell. 
The  patient  was  referred  by  Dr.  Charles  W.  Burr  on  March  9.  1915,  for  an  exami- 
nation of  his  ears,  not  only  to  determine  whether  his  hearing  could  be  restored,  but 
also  to  determine  whether  such  deafness  could  be  hysterical  in  origin. 

We  note  on  the  accompanying  chart  (XX)  that  high  tones  are  apparently 
heard  in  the  right  ear.  With  the  noise  apparatus  in  the  right  ear  he  apjjears  to 
hear  the  tuning-f6rk  placed  over  his  left  mastoid,  so  that  both  coehleas  retain  some 
function. 

Turning  produced  no  reaction  in  nystagmus,  vertigo  or  past-pointing,  indicating 
almost  a  complete  destniction  of  the  labyrinths  or  VIII  Ner\-es. 

Douching  showed  a  very  marked  impairment  of  responses  on  both  sides.  Con- 
tinuous douching  for  3  minutes  and  35  seconds  on  the  risrht  side  and  2  minutes  and 


324  EQUILIBRIUM  AND  VERTIGO 


CHART  XIX  A 


Name       A-w-^^    cV^  Age   3f  V>^i<tJL^-  f.  >')>(' 


DIAGNOSIS: 


SUMMARY: 


Complains  of      yx.-U-vv->^2*^<--C' 


HISTORY: 

Dizziness     -'r<r\*^ 
Staggering    ■^■v^-^ 
Deafness       ^  t^ 
Tinnitus       ^y-«^ 


NOSE:       ~^-*^  ytJ^'r<- 
THROAT:      ^.t^yrX^-»-^ 


7- 


A  S      v^-A^  «-Zi-<'-t 


Fistula    ^-^eJZ^rC 


^' 


Hearing  Tests  tL^lzXu  ^      j  '        ^  ^<iy(y^ 

k\2  Al^"         Ac    >      Be    <      n*^  Pol.  I  -  oM  ^'**«       Gait  |  •  / 

=  lo  1  o  Ac    ;      Be    f      D  I-  1    o  \y,^^       J7w^*^^.^zr 


PATHOLOGIC  CASES  ANALYZED 


325 


CHART  XIX  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


SPONTANEOUS 


NYSTAGMUS 

POINTING 

Looking  to  RIGHT   ^  t->^^ 

RIGHT 

LEFT 

Shoulder  from  above 

(Zf^i^a^^ 

<^3i^,,*-^6£-<^ 

Looking  to  LEFT    J}'4y^j(_ 

Looking  UP     c^^^ 

Nystagmus    A-r\/^^ 

Vertigo     ^,,^ 

Past-pointing     Jt-^vj. 

Looking  DOWN    -^--^^ 

Falling     J}-.(rvdU 

Romberg     yy^u/y^ 

Turning  head  to  right   '^'^  «-^C^ 

Turning  head  to  left     'A'jl^  aXCwt. 

Attempt  to  overthrow    ►^^  <t£*-c 

To  RIGHT    — > 
Amp.  (J\-^ 
Duration    ^  Sec. 


Tf.  LEFT     <: 

Amp.     t^ti^ryi. 
Duration  /J  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Ny stagm  u  s   ^  t^y  -  ^-*-*^ 
Vertigo    (^.....^-Ki'vvM.oZ 
Past-pointing    Sii*^CCc^,x^ 


To  LEFT 
Shoulder  from  above 


Nystagmus   •^yOA^'M/    -*.-o-i^ 
Vertigo  ^f^,^^  J'>-~^ 

Past-pointing    'p^Cc2C«^i^A^    >t*at«.n^ 


/JL''ua\^U'^\o'R,<^lt- 


A^i'toCfy  /S-"\a  ^/^ 


Douche  RIGHT    ^^~V 
Amp.     w  —t^ 
After     ''  min.  /•T  sec. 


Head  Back    — 
Amp.    ^rt-d. 

Douche  LEFT      ^Ij, 
Amp. 
After   ■/  min         sec. 


Head  Back     ^liru^ 
Amp. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  WytJa/cCtu    <!^e^rtW« 
Vertigo  ..       '  .,  ' 

Past-pointing     ^o>u*c.«-^ 
Falling      >/. 


Douche  LEFT 
Shoulder  from  above 


Nystagmus    ■A-v\*^^ 
Vertigo    J^ndt 
Past-pointing     ei^-ruut. 
Falling      ^^ 


C"  to7(?y)i(<3"to  Tf^zCr 


^■•to?p.^J  ^••to'/fc^i6r 


(^?^ 


^iii^jlfLiM      ^^<^e-^A-/. 


^^-^S^ 


•S^^Ic^*^ 


326  EQUILIBRIUM  AND  VERTIGO 


CHART  XX  A 

Nanae    tLjU<.     M .  &.  Age  Al  Date  4^   f-  'V^ 

Referred  by  Q^    '^ I^aJx^    JJ  ■  J'^m^k/^. 


DIAGNOSIS: 


SUMMARY: 


Complains  of      ^<r.><*f^^^  ,d^,,f.^t^    *»-**^   ^' 


HISTORY: 

Diiziness  ?t-»vv/^ 

Staggering  X*^    -v-*^  ^^  *f.*^ 

Deafness  i/c«. 

Tinnitus  Vwv«x, 


NOSE:      Jiyl  ^LtA^Z»-LL^ 

THROAT:     -^^-oM^  .      -^o    ''i<'^:CLMx*A.^c^    ^ 


EARS: 


Fistula     w//'-<^  xixS-*/* 

Hearing  Tests  .  ,9--  .  .  ,,,.1.7''  ;?ia£^ 

A I   ?  A  I    ?  Ac     <     Be     <      n  Pol.  |  -  c«  '3'<».^  Gait    '  /    "  ' 

=  1  o  I   o  Ac      <      Be     <      D  I-  I    O  '*-~^ 


PATHOLOGIC  CASES  ANALYZED 


327 


CHART  XX  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT    -^ 
Looking  to  LEFT /<^^S>^    ^ 
Looking  UP      ^rin^JL' 
Looking  DOWN    >^^ 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 


LEFT 


Nystagmus    ^^j-fj-,   A-'^-^jjf     - 
Vertigo     .^r»,^t- 
Past-pointing    ^/rv>.e^ 
Falling     .A*>v£- 

Romberg  Qtn^tA^dji/^tMti,  /,*v»y/vA.-a 

Turning  head  to  right    ^c^UJd.    ,<,j^  /■. 

Turning  head  to  left 

Attempt  to  overthrow    Vv*-u*>,<t^   ^AjLyj't^c^ 


TURNING 

To  RIGHT        Jh^ryy^ 
Amp. 

To  RIGHT 
Shoulder  from  above 

^^^^u^a^ 

^5w:*/^ 

Duration    O  Sec. 

1 
Nystagmus    ~^*<.t.**J' 
Vertigo   -^  Ua^^/ 
Past-pointing     y/l  Lc«4>/ 

To  LEFT       -^-.TK^- 
Amp. 
Duration    O  Sec. 

Nyst 
Verti 
Past- 

To  LEFT 
Shoulder  from  above 

igmus    ^  i^y^A^ 
go    JUma^ 
pointing    J^Lv^a^J- 

/"to/»^ 

'-^(,f^4HV-^C-«^ 

Douche  RIGHT  /^^ 
Amp.  2/bw  tLUi,mJbL 
After  3  min.  3f  sec. 

V-f"  AjtytyT\t.*l^  . 

Head  Back 
Amp.    ^^I^tmX^ 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus    Jf.!,*^  ,4*^ /»<*<'*♦ 
Vertigo         J-f^^^cC 
Past-pointing   J'fxt'x^ 
Falling  jUi^,^ 


Douche  LEFT     IT) 

Amp. -^M^Zy  j()*AeA./ilil^ 
After  ^   min. 3*  sec. 


Douche  LEFT 
Shoulder  from  above 


to 


<g^;i^ 


;!••  to/^ 


iL^tAjt^  '"'^^'^^x-t^/iA^ 


Head  Back 
Amp.       yiv-tMi-' 


Nystagmus     ^H^t^^'-*^    yr-c-i^t^ 

Vertigo     oltA..c.t2Z^u,o^.6-fc 

Past-pointing     r^^^.^.^^  ^.UZt^S.  U<U^ 


oj;:^^ 


3^28  EQUILIBRIUM  AND  VERTIGO 

30  seconds  on  the  left  side  produced  a  slight   reaction  in  nystagmus,  showing-  that 
some  function  still  remained. 

The  findings  of  the  vestibnlar  examination  in  this  case  would  indicate  almost 
a  complete  destruction  of  either  the  VIII  Nerves  or  both  labyrinths.  In  view,  how- 
ever, of  the  history  of  the  case  and  the  absence  of  associated  paralysis  of  the  VII 
Nen'es  or  other  cranial  nerves,  the  probabilities  are  that  the  VIII  Nen-es  are  intact, 
but  that  the  patient  sustained  a  fracture  into  his  labyrinth,  the  fracture  running 
through  the  petrous  portion  of  both  tempoi-al  l)ones. 

The  interesting  feature  about  this  case  was  the  difficulty,  ])y 
means  of  neurologic  studies,  to  exclude  hysteria.  Because  of  the 
absence  of  any  other  symptoms  except  the  deafness,  hysteria  was 
naturally  suspected.  It  is  excluded,  however,  by  the  ear-tests, 
which  indicate  a  definite  organic  lesion.  The  tuning-fork  tests 
alone,  depending  as  they  do  upon  the  patient's  statement  whether 
he  hears  them  or  not,  can  not  be  definitely  relied  upon  in  a  differ- 
ential diagnosis  between  hysteria  and  an  organic  lesion.  Generally 
speaking,  we  are  not  yet  in  a  position  to  state  definitely  that  hys- 
teria could  not  block  the  vestibular  responses  to  turning  or  douch- 
ing; our  belief  is  that  hysteria  could  not  abolish  the  simple  reflex 
of  nystagmus.  In  this  case,  however,  we  have  definite  evidence  of 
retained  function  in  the  vertical  semicircular  canals  of  both  .laby- 
rinths, especially  the  right,  because  douching  the  right  ear  does 
produce  nystagmus  and,  although  it  is  a  poor  reaction,  yet  it  is  a 
reaction  all  the  same.  The  horizontal  canals,  on  the  other  hand, 
show  no  responses  at  all.  It  is  inconceivable  that  a  condition  like 
hysteria  could  aff'ect  the  cochlear  portions  of  the  labyrinths  or  VIII 
Nerves,  also  the  fibres  from  the  horizontal  semicircular  canals  and 
leave  a  few  of  the  fibres  from  the  vertical  semicircular  canals  still 
functionating.  As  near  as  could  be  determined  by  the  tests  for  hear- 
ing, the  cochlear  i)()rtions  were  not  completely  destroyed.  There 
is  no  question  that  both  horizontal  canals  showed  no  function  what- 
soever. There  is  also  no  question  that  both  vertical  setnicircular 
canals  of  both  sides  showed  some  function  remaining ;  such  a  com- 
bination of  findings  could  not  be  due  to  liysteria.  As  this  case  is 
not  one  of  hysteria,  the  prognosis  is  therefore  absolutely  bad  as 
regards  any  return  of  hearing.    This  case  emphasizes  the  necessity 


PATHOLOGIC  CASES  ANALYZED  329 

of  a  vestibular  exaniination  in  every  case  of  suspected  hysterical 
deafness. 

Case  8. — Mr.  Angelo  G.,  age  50.  Patient  was  admitted  to  the  Philadelphia 
General  Hospital  on  June  10,  1916,  complaining  of  vertigo,  staggering  and  headache. 

The  histor>'  obtained  from  the  family  was  indefinite;  the  patient  stated  that 
one  3'ear  before  admission  he  had  fallen  and  struck  his  head.  His  family,  how- 
ever, denied  this  and  stated  thai  in  September,  1915,  the  patient  had  had  a  sudden 
chill  accompanied  by  great  pani  in  the  head  and  back  of  neck.  At  this  time  he  was 
first  treated  for  typhoid  fever  and  later  a  diagnosis  was  made  of  "hemorrhage  in 
the  brain."  He  recovered  from  this  acute  attack  and  it  was  noted  that  in  January, 
1916,  he  was  unable  to  hear  in  the  right  ear.  Recently  he  has  also  lost  his  hearing 
in  the  left  ear.  Throughout  the  entire  period  of  the  original  attack,  nine  months 
ag'o,  he  had  suff^ered  from  more  or  less  continuous  headache  and  frequent  attacks 
of  vertigo.     The  patient  has  a  wife  and  child,  in  good  health. 

On  admission  the  patient  was  scarcely  able  to  walk  and  reeled  towards  tlie 
left  side.  He  was  mentally  depressed,  reflexes  were  all  exaggerated,  clonus  was 
absent  and  he  complained  chiefly  of  severe  occipital  headache.  The  provisional 
neurologic  diagnosis  was  made  of  lesion  of  the  left  cerebellar  hemisphere. 

Referring  to  the  chart  (XXI)  of  the  ear-examination  we  note  that  the  tuning- 
fork  tests  indicate  markedly  decreased  function  of  each  cochlea.  The  spon- 
taneous nystagmus  indicates  a  disturbance  in  some  portion  of  the  vestibular  ap- 
paratus. The  turning  and  douching  tests  show  an  entire  absence  of  all  responses — 
nystagmus,  vertigo,  past-pointing  and  falling — on  stimulation  of  each  of  the  semi- 
circular canals  of  both  ears. 

Obviously  the  otologic  diagnosis  was  a  bilateral  perip}ieral  lesion.  There  was 
such  a  definite  absence  of  all  responses  on  stimulation  of  the  vestibular  portion  of 
each  internal  ear;  furthermore  the  marked  cochlear  impairment  corroborated  this 
viewpoint.  The  following  report  was  made :  "The  ear  examination  suggests  an 
almost  complete  destruction  of  both  labyrinths  or  VIII  Nerves.  We  believe  that 
the  VIII  Nerves  rather  than  the  labyrinths  are  involved  because  of  the  presence 
of  signs  of  an  accompanying  low-grade  basilar  meningitis  (Fig.  114).  This  view- 
point would  also  account  for  the  presence  of  a  low-grade  fever,  which  is  present  in 
this  case.  We  would  suspect  a  general  toxaemia  of  a  virulent  type,  such  as  syphilis, 
and  feel  that  the  attack  last  fall  was  caused  by  an  involvement  more  particularly 
of  the  right  VIII  Nerve,  and  that  the  present  vestibular  symptoms  have  been 
caused  by  a  recent  involvement  of  the  left  VIII  Nerve." 

The  Wassermann  test,  performed  subsequently,  was  reported  strongly  posi- 
tive, both  for  the  blood  and  for  the  cerebi'o-spinal  fluid.  Under  anti-syphilitic 
treatment  the  patient  improved ;  the  staggering,  ataxia  and  headache  were  relieved, 
but  there  was  no  improvement  in  the  hearing. 

Casbj  9. — Mr.  Elberson  L.,  age  52.  Patient  was  admitted  to  the  University 
Hospital  on  October  9,  1915,  to  the  service  of  Dr.  William  6.  Spiller,  with  the 
chief  complaint  of  "weakness  in  the  right  leg."  He  gave  the  following  history: 
Five  months  before  admission  he  had  what  he  called  a  "stroke."  which  was  ushered 
in  with  nausea  and  vomiting.     The  day  following  the  attack  he  was  woree  and,  in 


330  EQUILIBRIUM  AND  VERTIGO 


CHART  XXI  A 


^zm^J^do    &.  Age    cTo  Date     (o/>^fl(,. 


Addres 


Referred  by    y>ut^A-o6fc-^&^.«-<»_    ^<x.c-c/»xiX    Jf/it^ajCXA^C 


DIAGNOSIS: 


SUMMARY: 


Complains  of  V-IaX^^o  ,   aJ^o^  q^A-'-'^    <^**^     iU^o.^^-a.x/uu. 


T'"^r^ 


HISTORY: 

Dizziness  <i</9y 
SUggering  g't^ 
Deafness  ^^^ 
Tinnitus      ijfuty 


NOSE:        ^-^<JZv<, 
THROAT:     '^-^<xZl-«- 

A.  D.  9x^j(a.<uil/.  j{.  ^r~ 

Fistula    '■^-^^auCC^rl, 

Hearing  TesU  f^~  ^<,^Cf^ 

Al/  A|f  Ac>Bc<n  Pol.  |  c'  P^-— -         Gait  I  ^, 

=  10  \o  Ac     >      Be    <       n  I  lSC~^  I 


EARS: 


PATHOLOGIC  CASES  ANALYZED 


331 


CHART  XXI  B 


NYSTAGMUS 
Looking  to  RIGHT     -^— 

Looking  to  LEFT  =^ 

Looking  UP    '^^«-^-t^ 
Looking  DOWN  w^ 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 

Shoulder  from  above 


POINTING 


RIGHT 


Nystagmus   ■^'^.-^^ 
Vertigo      'iJ<-<y 
Past-pointing     y^ 
Falling     JT  <<t^ 

Romberg       f,jCU.    if  ^<^~ 

Turning  head  to  right  \   ^^,^,^^^^J^    ^  Xi^U.    i^^«^t. 

Turning  head  to  left      > 

Attempt  to  overthrow^     -^    t^^^MJ^^i^ 


LEFT 


To  RIGHT    rr^-*^*^ 

Amp. 

Duration         Sec. 


To  LEFT      Jl-Afx^ 
Amp. 
Duration         Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    -^K 
Vertigo     Jh^rv^ 
Past-pointing       .A-, 


To  LEFl' 
Shoulder  from  above 


Nystagmus    ^' 
Vertigo  Jlr^ 
Past-pointing     »//v 


^^^:xe44-t 


<^u:::zuu. 


?(*»--»^«..^ 


^uZuJU^ 


CALORIC 

Douche  RIGHT    -^^t-*- 
Amp. 
After  jr"min.        sec. 

Nyst 
Verti 
Past- 

Douche  RIGHT 
Shoulder  from  above 

agmus    yhcn^jL, 
go     A-,^,u^ 
pointing     ~/h^-^AJL^ 

^u::zj^ 

<^w*A^ 

Head  Back    J'-r^^-t- 
Amp. 

Falhng       Jh.a-,.^ 

6JZmJj^ 

'vw«-*^«-^ 

Douche  LEFT    Jr^rx^^ 
Amp. 
After  d~  niin.        sec. 

Nyst 
Verti 
Past- 

Douche  LEtT 
Shoulder  from  above 

agmus    -''r>>»-€' 

go          JkrydL. 

pointing      yYtrvJt^ 

(jj:suu 

(^^xZZi/'^c 

Head  Back    ^.rwL 
Amp. 

Falli 

^8       A.'Ti.-Jt^ 

9JZ2UJL 

'vi»«'<-«-***C 

ss-^ 


EQUILIBRIUM  AM)  VERTIGO 


addition  to  the  nausea  and  vomiting-,  lie  bad  severe  vertigo.  On  the  third  day  he 
began  to  experience  difficulty  in  swallowing.  Walking  became  impossible,  so  that 
he  had  to  be  taken  to  the  hospital  in  an  ambulance.  At  this  time  he  had  severe 
shooting  pains  in  the  right  side  of  the  head,  which  radiated  to  the  rig-ht  side  of  the 
face  and  into  the  riffht  eve.     His  voice  was  thick  and  the  ditTiculty  in  swallowitig 


RIGHT 


LEFT 


Dotted  lines  indicate  Ideation  of  lesion. 


became  so  marked  that  lie  had  to  be  fed  thi'ough  a  glass  tube.  There  was  excessive 
secretion  of  saliva.  The  right  leg  and  foot,  he  said,  were  extremely  weak,  but  the 
condition  probably  was  one  of  inco-ordination. 

There  was   nothing  of  significance   in   the  previous  medical   or  social    history. 
He  denied  the  use  of  alcohol  or  tobacco  or  any  history  of  specific  infection.     On 


PATHOLOGIC  CASES  ANALYZED  333 

admission,  the  following  notes  of  his  i)hysit'al  examination  were  made:  "  The  patient 
is  a  Avell  nourished  adult,  with  no  evidence  of  maldevelopment  of  any  kind.  Pupils 
are  unequal,  the  right  being  smaller  tlian  the  left;  both  react  normally  to  light  and 
accommodation.  Extra-ocular  muscles  normal.  No  facial  palsy.  Tongue  pro- 
trudes in  midline.  On  the  right  side  of  the  face  there  is  loss  of  sensation  for  heat, 
cold  and  pain,  but  not  for  touch.  Chest  and  abdomen  negative.  There  is  no  weak- 
ness of  the  upper  lindjs.  The  reflexes  are  pi-esent  in  the  right  upper  limb,  but  di- 
minished in  the  left.  Patellar  reflexes  are  diminished  in  both  lower  limbs.  No 
Achilles  jerk.  No  ankle  or  jiatellar  clonus.  When  tests  for  the  Babinski  sign  are 
made  there  is  a  downward  motion  of  the  big  toe  on  the  right  side  and  no  motion 
in  the  big  toe  on  the  left  side." 

Notes  dictated  by  Dr.  Spiller:  "On  the  left  side  of  face  along  tlie  edge  of 
the  lower  jaw  in  the  distribution  of  the  upper  cervical  nei-ves,  warmth  is  not  as 
acutely  felt  as  in  the  corresponding  part  of  the  riglit  side  of  face.  In  the  distri- 
bution of  the  middle  branch  of  the  V,  the  impairment  of  warmth  is  distinctly  more 
marked  on  the  right  side  than  on  the  left  side.  The  impairment  of  warmth  is 
distinctly  greater  in  the  distribution  of  the  first  branch  of  the  left  V  than  in  that 
of  the  second  branch.  The  impairment  of  pain  sensation  is  very  marked  in  the 
distribution  of  the  right  V  and  sliarply  confined  to  this  distribution.  Impairment 
of  jiain  sensation,  like  that  of  heat,  is  distinctl}'  greater  in  the  left  upper  limb  than 
in  the  left  lower  limb,  but  this  impairment  is  distinct  in  the  lower  limb  and  very 
distinct  in  left  side  of  trunk.  There  is  slight  impairment  of  pain  sensation  in  the 
distribution  of  upper  cervical  nerves  over  the  left  inferior  maxillary  bone.  There 
is  slight  weakness  of  the  right  side  of  soft  palate.  He  still  occasionally  has  diffi- 
culty in  speaking  and  swallowing,  and  at  the  onset  of  the  disease  he  was  hoarse  and 
spoke  in  a  whisper.  Right  conjunctival  and  corneal  reflexes  greatly  impaired — 
almost  lost.  Left  conjunctival  reflex  entirely  normal.  Tactile  sense  is  nonual  in 
all  parts  of  the  body.  No  involvement  of  the  tongue.  There  is  numbness  in  the 
left  side  of  the  body.  Finger-to-nose  test  shows  a  slight  dysmetria,  only  in  the 
right  hand.  There  is  a  slight  adiadokokincsis  in  the  right  hand,  both  in  touching 
the  palm  and  dorsum  of  the  hand  alternately  on  the  right  thigh,  and  in  rotating  the 
right  hand  at  the  wrist  without  touching  the  thigh.  Sweeping  the  upper  limb  as 
far  back  as  possible  and  bringing  it  back  so  as  to  place  the  finger  on  the  end  of 
the  nose,  the  right  upper  limb  shows  marked  asynergia.  He  starts  with  a  sweep 
of  the  whole  upper  limb,  but  when  half  completed  the  movement  of  the  arm  is 
arrested  and  the  sweep  is  completed  by  flexion  of  the  forearm.  In  bending  back- 
ward as  far  as  he  can,  he  does  not  flex  either  knee.  The  synergic  movement  of  the 
right  lower  limb  is  practically  normal." 

Eye  report  bif  Dr.  Langdon:  "Pupils  are  unequal,  the  left  being  of  slightly 
irreg-ular  contour.  No  syneehiae.  Both  pupils  react  to  light,  accommodation  and 
convergence.  There  is  no  loss  of  power  in  the  orbicularis  muscles.  There  is  no 
liemianopsia  and  no  diplopia  could  be  elicited.  The  media  are  clear;  the  discs, 
however,  are  hyperaemic.  with  binned  nasal  margins.  The  arteries  are  large  and 
their  walls  have  an  increased  reflex.  There  are  no  liemorrhages,  but  the  picture 
sugo-ests  ai'terio-sclerosis." 

The  Wassermann  test  was  negative. 


334 


EQUILIBRIUM  AND  VERTIGO 


CHART  XXII  A 


Name 


^  U^iAy^'irv^    "C- 


Age   <rj  Date  /<rj /S-//i 


Address 


Referred  by  Q^   J?^tZ^.«u^    ^   ^JUUy  . 


DUGNOSIS: 


SUMMARY: 


Cotoplains  of    M p^^^^^^^,  fi^^  lA*^   -x-V  ^^ 


HISTORY:  _, 

Dizziness    J/m^  ^a^  A-tx-n*/-    a.U^j:A^  /a. 
Staggering    J^^a^,     V    >.-*v<JZA<- 
Deafness    ^o^*^ 
Tinnitus     Jf-r.^£, 


j^Cx'    ^.tn.J. 


Z*         "/l^C4-*-<C«- 


NOSE:     ^.o-/n^   MiXixA^  <£Zuij6^*«' 


THROAT 


^,:z:if  ^^iv*^:^  .  0«-  A^.^0   '-^^ '  Xlx.  x^-u^*/^  .<^  ,<^^^i^./v^ 


EARS 


A.s.  j}(.^\,.ju^  utM.  La  >-»-<u/e. 

Fistula     -^Ji4f -tkXZt^ 


Hearing  Tests 

AI3 

A|9 

Ac    > 

He     < 

n 

Pol. 

=  l3 

1? 

Ac    > 

Be    < 

n 

i^t/^ 


(.«  iS'*^        Gait  I'-  -2  _, 


PATHOLOGIC  CASES  ANALYZED 


335 


CHART  XXII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT  -V>v-^ 
Looking  to  LEFT    ^-"t^-*- 
Looking  UP   -'^^'1**' 
Looking  DOWN  -^ 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus  yriru^ 

Vertigo    A'.rx^ 

Past-pointing     ■j^-<rvot^ 

Falling      ,C^^  ^  <t..c^^..<,c,iU^aJUt,   aZ^aa^. 

„  ,  .  ^  uming  head  to  right     ''-o  A-f^A^^^ 

y^rv-tL  .       K<p-  /^yi»^  Ay-c^   Turning  head  to  left  e-A^^^^^^  /^^  xi*r^,,>,^>  ^^^u»/^„-^ 
X^C^c^^A,  T^jJa  iU-  Attempt  to  overthrow  -i-ortc^  -o-'-*^iZlA^tiUXc^.^y  Ayi.ijL^A^  jUtj  '^^rfCi-^A-  A>la^*^x^ 


To  RIGHT 


^ 


Amp.     a-OT)-*^ 
Duration  Zo  Sec. 


To  LEFT   < 

Amp.  "a^-t-rft 
Duration  -?4  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    ^.«-a*-'^-a£. 
Vertigo     Jf-^A^^^j.^oJi 
Past-pointing    •A-jtA^.^^^oJi 


To  LEFT 
Shoulder  from  above 


Nystagmus    Jt-a'y^.'^^aJL 
Vertigo     v/^*a.o.^-«^ 
Past-pointing      yv-^tjUtj^ 


Douche  RIGHT   /^ 
Amp.  Jx>-'^/Ly 
After    /  min.        sec. 


Head  Back    ■ — ^ 
Amp.  <^V>-^£, 

Douche  LEFT    *0 
Amp.    ^U~o-A 
After        min..^o  sec. 


Head  Back  .^ 

Amp.   KiU^'ra.l 


CALORIC 

Douche  RIGHT 

Shoulder  from  above 

Nystagmus     Ji'*'^^^'^^^ 
Vertigo   ■m.ojJ^xJ.  ,  umXL 
Past-pointing 
Falling 

Douche  LEFT 
Shoulder  from  above 

Nystagmus      a»-o-<t 
Vertigo    yf-^A^uu-^X, 
Past-pointing    ^»A^uu..eJL 
Falling      ^^,/UAA.^>jt, 


LEFT 


"-o^<Ja.-%<tk.'rTt. 


/?\o%-^-I3l'\o  T^^CJ- 


/;?-  \.oC^ 


;i^'lo>(^ 


^.. 

toTfi^ 

A>-trvji.dU,*-n 

(^JTTaA.j 

S-' 

to/?^ 

^' 

to^^ 

(o  "to  mqi-t" 

4  "to  K<^ 
i^"  to  ■^S^ 


836  EQUILIBRIUM  AND  VERTIGO 

We  have  pi'eseiited  the  complete  neurolog'ic  data  in  this  case  for  a  particular 
reason.  Dr.  Spiller  had  made  a  diagnosis  of  "Thrombosis  of  tlie  right  pos- 
terior inferior  cerebellai-  artery."  The  patient  presented  the  classical  symptom- 
complex  of  this  lesion;  Dr.  Spiller.  Dr.  II.  M.  Thomas  and  others  have  i)re- 
sented  identical  cases  with  histologic  examination.  Dr.  Spiller  therefore  sent 
the  patient  for  an  ear-examination  with  the  following  note:  "This  patient  exhibits 
the  definite  symptom-complex  of  a  certain  lesion  in  a  detinite  localized  area.  We 
have  histologic  knowledge  of  identical  cases  and  therefore  we  can  be  as  sure  as 
is  humanly  possible  of  the  correctness  of  the  diagnosis.  It  would  therefore  be 
valuable  to  know  what  the  ear-tests  would  indicate  in  this  particular  case." 

The  data  of  the  neurologic  examination,  which  we  have  just  presented,  were 
known  only  to  Dr.  Spiller,  and  the  ear  rei)ort  was  made  exclusively  on  the  basis 
of  the  ear-examination,  by  the  turning  and  douching  tests. 

A  glance  at  the  accompanying  chart  (XXII)  would  at  first  seem  to  indicate 
that  all  the  responses,  both  to  turning  and  douching,  were  normal.  There  is  just 
one  isolated  abnormality — douching  of  the  right  ear  with  the  head  back  60°,  al- 
though eliciting  a  normal  nystagmus,  produced  no  vertigo  and  no  past-pointing. 
In  other  words,  the  right  horizontal  canal  itself  was  normal,  because  it  produced  a 
normal  nystagmus  and  yet  this  stimulation  of  the  right  horizontal  canal  failed  to 
produce  vertigo  and  past-pointing.  With  this  one  exception  all  the  responses  in 
nystagmus,  vertigo,  past-pointing  and  falling  froni  all  the  semicircular  canals  were 
entirely  normal.  The  labyrinth  and  VIII  Nerves  were  therefore  evidently  normal. 
The  iJons  appeared  to  be  uninvolved.  because  the  responses  from  the  vertical  canals 
of  both  ears  were  normal.  Tiie  cerebellum  itself  would  appear  to  be  unat¥ected 
because  the  vertigo  and  past-j)ointing  were  normal  on  stimulation  of  all  the  semi- 
circular canals  except  the  right  horizontal;  a  normal  cerebellum  is  indicated  if 
stimulation  of  any  canal  or  canals  produces  a  normal  past-pointing  of  both  upper 
extremities  in  both  directions.  A  gross  lesion  of  the  cerebellum  itself  will  interfere 
with  vertigo  and  past-pointing  no  matter  what  canal  is  stimulated.  With  a  normal 
horizontal  semicircular  canal,  normal  fibres  from  the  horizontal  canal  within  the 
YIII  Nerve,  normal  pathways  to  the  posterior  longitudinal  bundle,  resulting  in  a 
nomial  nystagmus,  and  a  normal  cerebellum,  an  interruption  of  the  impulses  for 
vertigo  on  stimulation  of  the  horizontal  canal  would  therefore  suggest  a  block 
within  the  right  inferior  cerebellar  peduncle.  The  following  report  was  made  : 
"The  ear-tests  suggest  a  lesion  at  the  junction  of  the  medulla  oblongata  and  pons 
on  the  right  side,  in  the  region  of  the  right  inferior  cerebellar  peduncle,  not  in- 
volving the  posterior  longitudinal  bundles."  Necropsies  obtained  in  cases  of 
occlusion  of  the  postei-ior  inferior  cerebellar  artery  have  shown  that  the  lesion  is 
always  situated  in  this  pai't  of  the  medulla  oblongata. 

Case  10. — Mr.  S.  H.,  age  29.  In  July,  1914,  tiie  patient  was  seized  with  a 
sudden  attack  of  vertigo,  staggering,  nausea  and  vomiting.  External  objects  seemed 
to  move  around  and  around  in  front  of  him.  The  diagnosis  made  was  ptomaine 
poisoning.  The  patient  noticed  a  distinct  improvement  every  day  for  three  weeks 
and  then  things  settled  down  into  a  continuous  state  of  dizziness  but  without  nausea 
or  vomiting.  Throughout  the  attack  there  was  no  tinnitus  and  no  impairment  of 
hearing. 


PATHOLOGIC  CASES  ANALYZED  337 

Ear  Examination.  Referring-  to  the  chart  (XXIII),  we  note  a  slight  rotary 
nystagmus  on  looking  to  the  right.  Turning  with  the  head  upright,  testing  the 
horizontal  canals,  produced  distinctly  subnormal  nystagmus,  vertigo  and  past- 
pointing.  Douching  the  right  ear  with  the  head  upright,  testing  the  right  vertical 
canals.  ]u-oduced  poor  responses;  douching  the  left  ear  similarly  produced  im- 
paired responses — in  fact,  practically  no  nystagmus,  vertigo,  past-pointing  or 
falling. 

This  examination  was  made  over  three  years  prior  to  this  writing.  Based  on 
the  fact  that  all  responses  from  all  the  canals  of  both  ears  were  impaired,  a  diag- 
nosis of  involvement  of  both  labyrinths  was  made.  Note  was  made  at  the  time 
that  this  diagnosis  was  not  compatible  witli  the  normal  condition  of  both  eochleas 
and  witli  certain  of  tlie  findings  by  turning  and  douching.  This  diagnosis  of  double 
peripheral  lesion  aj^peared  to  be  corroborated  in  that  subsequent  neurolog-ic  exami- 
nation failed  to  reveal  anj'  evidence  whatever  of  intracranial  involvement.  This 
diagnosis,  however,  was  not  convincing  and  the  patient  was  advised  to  report  fre- 
c(uently  for  further  tests.  Examination  a  few  months  later  showed  practically  no 
nystagmus  after  turning  to  the  right  or  to  the  left  with  the  head  upright,  and  yet, 
with  the  head  placed  60°  backwai'd,  turning  to  the  right  and  to  the  left  x^i'oduced  a 
large  rotary  nystagmus.  It  was  obviously  impossible  to  explain  this  phenomenon 
on  the  basis  of  an  end-organ  lesion ;  a  report  was  made  that  the  previous  diagnosis 
of  labyrinthitis  Avas  apparently  wrong  and  that  the  case  was  one  of  intracranial 
involvement.  Even  at  that  time,  however,  there  was  no  demonstrable  neurologic 
evidence  of  an  intracranial  lesion. 

Later  there  appeared  a  si)ontaneous  vertical  nystagmus,  both  upward  and 
downward,  of  the  left  eye  only ;  also  a  spontaneous  past-pointing  of  both  upper 
extremities. 

The  patient  at  the  present  time  shows  unmistakable  evidence  of  an  intracranial 
lesion,  most  probably  a  low-grade  tubercular  basilar  meningitis.  Corroborating  this 
view,  it  is  to  be  noted  that  a  gland  became  gi'eatly  enlarged  just  behind  and  below 
the  riglit  mastoid:  this  gland  was  removed  and  microscopic  examination  showed  it  to 
l)e   tuhcrrular. 

Considering  this  case  from  a  purely  otologic  standpoint,  a  glance 
at  the  chart  will  show  that  our  original  diagtiosis  was  not  justified. 
The  conclusion  of  peripheral  lesion,  based  upon  an  impairment  of 
all  the  responses  to  turning  and  douching,  was  correct  as  far  as 
it  went ;  not  enough  attention,  however,  was  paid  to  the  following 
data  which  pointed  unmistakably  to  a  central  disturbance,  even  on 
this  first  examination : 

(1)  A  spontaneous  nystagmus  persisted  for  two  months  after 
the  original  attack  and  was  noted  at  the  first  examination. 

(2)  The  continuous  spontaneous  vertigo  was  by  no  means 
typical  of  involvement  of  the  labyrinth. 

22 


338  EQUILIBRIUM  AND  VERTIGO 


CHART  XXI II  A 


ddress  _  .  .  .  r 


Name 

Address  . 

Referred  by  ^^   77 J¥.    M/. 


DIAGNOSIS: 


SUMMARY: 


Complains  of    l/AAZCajr  ^o-^a^     oZo^aiA^^^ 


HISTORY:  , 

Dizziness  vA-<^ 

Staggering  ^^^ 

Deafness  'h.o 
Tinnitus         ~yio 


NOSE:      -^-^"^^^ 
THROAT:     o//-^"-^-^^ 

A.  S.     ^'  -^ 

'7 


A.  D.   c/r-e^^o^^^^ 


Fistula     Jfji^  ^^^^^.^^ 


Hearing  Tests  Z       /  -^  kJuC-'-^ 

A|//i.       A|  *^  Ac     >      He    <       n  Pol.  1  -  cM  V^m^      Galtl-^O  _^ 

-|//j  I   6  Ac     >       Be    <        n  I-  \^c.*^  i^'^ 


PATHOLOGIC  CASES  ANALYZED 


339 


CHART  XXIII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT        ^O 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 


Looking  to  LEFT    /!-«^<. 

Looking  UP      y^^''^^ 

Looking  DOWN     XfrM^ 

a      .  ——  .  Romberg     'h.t-jaXZtr^, 

/«.A*-^    oM^-U    aX/^^         Turning  head  to  right    Ks^U:.^ 


Nystagmus     ■J^i^  ~  '*^  /Wa  ^^  • 
Vertigo       i^K^ 
Past-pointing     >t-rvt^- 
Falling       >l<nA^ 


^U  vr^ 


Turning  head  to  left       ^  c^aUZv^ 
Attempt  to  overthrow     ^^^  etXi^ 


LEFT 


To  RIGHT    > 

Amp.    cMw^fc^^ 
Duration  lo  Sec. 


To  LEFT    < 

Amp.  '^^oUn^ 
Duration    /ySec. 


TURNING 

To  RIGHT 

Shoulder  from  above 

Nystagmus   •S'^<^^^'*^ 
Vertigo    d.»*.^-M,»/u-.-«c^ 
Past-pointing   cVX^wo^  -w-o- 


ToLEFT 

Shoulder  from  above 

Nystagmus  •■>^**yV«i*'v^-^ 
Vertigo    or4.c,^-M,«-A-.»w«X 
Past-pointing    »^At-,*-<i..^ 


/  '  to/»^ 


/'to     I^^^U 


4o  ^iriZ^UjLd. 


Douche  RIGHT  — =>    ''"^V 

Amp.  ^.-Cu^Ay   /C«   /4''~-nr 
After    /    min.  Aosec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


to 


Head  Back 
Amp.  Qa- 

DoucheLEFT    -. 

Amp. -3  •--ta.' yv^^>.^  A^**-*A 


Nystagmus  '<'^*^oua^^ 
Vertigo  QZtA.-^»,,«.'Uw<t.^ 
Past-pointing  .//^.^^^ 
Falling      (l't.-iji.,.U. 


Douche  LEFl' 
Shoulder  from  above 


After  A.   min.  «/osec.    ''^^    '-p^vZM^Ujt^nty*, 
^iJA-     C^    A^*...^^  A^^  Nystagmus     Vi^^r^  /^^..iXw^y 
'  /  I        Vertigo     7Z<rvut,  7 


Ziia 

Head  Back 
Amp.     ^Iri^je. 


■)U 


Past-pointing    c^A-«.<,A-e-<>je/y    >u>-n.t.- 
Falling    c>^  (U.,^.^^^  .  (7 


^^^^^eV. 


to 


/"to'^i.'^il^- 

' "  to  -<!,^ 


to 


340  EQriLIBRILM  AND  VERTIGO 

(3)  Douching-  the  right  vertical  canals  produced  a  horizontal 
nystagmus  as  well  as  a  rotary  nystagmus;  this  perverted  nystag- 
mus directly  indicated  intracranial  involvement  and  should  have 
pointed  the  way  to  a  correct  diagnosis. 

AVe  were  evidently  dealing  in  this  case  with  a  lesion  which  was 
both  peripheral  and  central,  and  was  therefore  most  probably  so 
located  intracranially  that  it  was  in  a  position  to  involve  ])oth 
VIII  Xerves.  If  our  original  diagnosis  had  been  a  neuritis  of 
both  VIII  Xerves,  instead  of  a  labyrinthitis,  it  would  have  been 
true  although  only  a  half-truth.  As  it  was,  our  original  conclu- 
sions were  altogether  erroneous  and  misleading;  it  was  only  after 
subsequent  examinations  that  the  ear  tests  made  a  correct  diagnosis 
of  intracranial  involvement.  The  fault  at  the  time  of  the  first 
examination  was  not  in  the  data  shown  by  the  tests,  but  in  our 
inability  to  understand  and  interpret  the  phenomena  which  we  now 
see  were  plainly  presented. 

Case  11. — ^Irs.  ('.  M.  D.,  ag-e  36.  was  admitted  to  the  University  Husi)ital  to 
the  services  of  Drs.  ]\Iills  and  Spiller  August  12.  191.").  having  been  referred  In* 
Drs.  S.  D.  Ludlum  and  .J.  W.  McConnell.  Her  eliief  conii)laint  Avas  vertigo  and 
inability  to  walk.  Slie  had  apparently  been  in  good  health  until  eight  weeks  before 
her  admission  to  the  hospital,  and  .^he  died  two  weeks  after  admission;  so  that  her 
entire  illness  Avas  of  only  ten  weeks'  duration. 

She  gave  the  following  history:  The  trouble  began  with  vertigo.  Two  weeks 
after  the  on.set  the  vertigo  was  so  marked  that  she  Avas  unable  to  Avalk;  she  stag- 
gered both  to  the  right  and  to  the  left.  At  this  time  she  began  to  haA'e  vomiting 
spells,  Avithout  precedent  nausea;  these  spells  continued  at  intervals  until  her  death. 
During  the  fourth  Aveek  of  her  illness  the  patient  noticed  tliat  the  right  limbs  were 
becoming  Aveak ;  this  impairment  steadily  increased  until  at  the  time  of  hei"  ad- 
mission to  the  hospital  she  could  scarcely  move  eitlier  the  right  upper  or  loAver 
extremities.  Five  Aveeks  from  the  time  of  onset  she  began  to  have  seA-ere  headaches 
and  in  the  sixth  Aveek  she  noticed  that  her  vision  was  failing.  No  symptoms  referable 
to  the  pulmonai-y.  cardiac  or  renal  systems.  Family  iiistory  negative.  exce]>t  that 
one  uncle  died  of  brain  tumor. 

The  folloAving  are  the  notes  of  Dr.  ^Mills'  examination,  made  immediately 
after  her  admission  :  "The  patient  lies  in  bed  in  the  supine  position.  Avith  the  head 
slightly  inclined  to  the  left.  She  has  a  typical  right-sided  hemiplegia  of  the  face, 
arm  and  leg.  Avith  moderate  hypertonicity ;  superficial  and  deep  reflexes  are  all 
increased,  foot  clonus  is  absent  and  plantar  stimulation  gives  plantar  flexion.  No 
paralysis  is  discoverable  on  the  left  side,  but  the  left  finger-to-nose  test  sIioavs  a 
distinct  ataxia,  the  uncertainty  being  of  small  excursion.     Sensation   for  jiain   and 


PATHOLOGIC  CASES  ANALYZED  341 

touch  is  everywhere  iioriiial.  Speecli  is  slow  and  dysarthrie,  but  nut  sutticiently  so 
to  make  it  inarticuhite;  she  answers  questions  sensibly  and  obeys  conmiands,  in 
so  far  as  she  is  physically  able.  The  right  eye  shows  slight  ptosis;  there  is  some 
weakness  of  the  external  rectus,  the  internal  rectus  and  the  superior  and  inferior 
obliques.  The  left  eye  shows  ptosis  and  weakness  in  all  ocular  movements ;  move- 
ments of  the  musculature  supplied  by  the  III  Nerve  are  almost  completely  abol- 
ished. Conjugate  movements  are  lost  in  all  directions.  The  pupils  are  unequal, 
the  right  being  larger.  The  pupils  react  to  direct  light  stimulation,  but  the  con- 
vergence response  is  questionable." 

Dr.  B.  F.  Baer,  Jr.,  reported  marked  papilla'denia,  worse  in  the  left  eye. 

The  ear  examination  was  made  innnediately  after  admission  and  the  findings 
are  shown  on  the  accompanying  cliart  (XXIV).  Tiie  following  deviations  from 
the  normal  are  to  be  noted : 

(1)  There  is  a  spontaneous  nystagmus  in  every  direction;  the  vertical  nys- 
tagmus upward  is  the  most  significant,  because  it  is  suggestive  of  an  involvement 
of  the  brain-stem. 

(2)  Turning  to  the  right  produced  a  rolari/  nystagmus  to  the  left  instead  of  a 
horizontal  nystagmus;  this  "perverted"  nystagmus  is  also  indicative  of  a  brain-stem 
lesion. 

(IV)  Turning  to  the  right  and  to  the  left  pi'oduced  a  distinct  eye  movement,  but 
no  vertigo  whatever.  This,  per  se,  would  suggest  an  interference  with  the  path- 
ways from  both  horizontal  canals  to  the  cerebral  cortex,  at  the  point  of  the  decus- 
sation of  the  superior  cerebellar  peduncles  in  the  base  of  the  cerebral  crura. 

(4)  Douching  the  right  ear,  with  the  head  30°  forward,  which  stimulates  the 
right  vertical  canals,  fails  to  produce  any  responses  whatever.  This  suggests  in- 
volvement of  the  vertical  canals  fihres  in  the  right  side  of  the  pons. 

(5)  Douching  the  right  ear  with  the  head  back  60°,  stimulating  the  right 
horizontal  canal,  on  the  other  hand,  does  produce  a  movement  of  the  eyes;  this 
would  indicate  normal  pathways  in  the  medulla  oblongata. 

(6)  It  must  be  noted  that  turning  and  douching  would  for  the  most  part  pro- 
duce a  conjugate  deviation  of  the  eyes  instead  of  a  nystagmus;  the  only  instance 
in  which  there  was  a  real  nystagmus  was  after  turning  to  the  right.  This  inter- 
ference with  almost  all  of  the  impulses  Avhich  would  normally  cause  the  quick 
recoil  of  the  eyes — the  cerebral  component  which  completes  a  real  nj'staginus — 
would  indicate  a  lesion  at  the  junction  of  the  cerebral  crura  at  the  i^oint  where  the 
cerebro-ocular  fibres  from  both  sides  of  the  cerebral  cortex,  come  together  to  be 
distributed  to  the  eye-muscle  nuclei. 

(7)  There  is  a  striking  absence  of  vertigo;  no  vertigo  whatever  was  produced 
by  stimulation  of  any  canal  except  the  left  vertical  canals,  which  did  produce  a 
noticeable  vertigo.  Even  this  vertigo,  however,  was  very  slight ;  the  patient  merely 
stated  "that  made  me  a  little  dizzy." 

Analysis. — Both  labyrinths  and  both  VIII  Nerves  are  apparently  normal,  be- 
cause both  cochleas  were  normal  and  stimulation  of  each  ear  produced  some  normal 
responses.  The  medulla  oblongata  appeared  to  be  nonnal  because  stimulation  of  the 
horizontal  canal  of  each  ear  produced  a  normal  eye-movement ;  the  conjugate  devia- 


34'2  EQUILIBRIUIM  AND  VERTIGO 


CHART  XXIV  A 


Name     ~^\M^ 
Addie 


^.-^^.  Age    ^^  Date    Sy/lZ/S'. 

Referred  byQ^   J^   _^    ^^    ^.Z^ 


DIAGNOSIS: 


SUMMARY: 


lins  of    U  Ui^U^a    ^OM^ 


Complains  of    U -iA^a    .c^^    yy^,^Ju-,jt.«^ 


HISTORY:  . 

Dizziness  -^t^*- 
Staggering  .^C^^ 
Deafness  ^^^^ 
Tinnitus     ^,^,^ 


NOSE:        -^J^cJZ^ 
THROAT:    .J- ■'^  cJ^"-^ 

A.  D.    \yhe^ aX-^o^, 

EARS: 

Fistula     ^/'-Ca.aJtZu-i, 

Hearing  Tests  a 

A|5,  Al/  Ac    >       Be     =      n  Pol.  I  c' I 'Si,^        Galtj.^ 


PATHOLOGIC  CASES  ANALYZED 


343 


CHART  XXiy  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT    ■^ 
Looking  to  LEFT 


SPONTANEOUS 

Shoulder  from  above 


RIGHT 


POINTING 


't^^-o-'^^vu^  Nystagmus    c/t-^-' 

Looking  UP      -^  Vertigo     Sjyf^ 

■'y^-'-'^^^'-oyu)!^  Past-pointing     il<^ 

Looking  DOWN  Falling      lu^ 

i^,,,^^  Z^U  ^.oiu^  .r^.x::u.  R°»berg    - 

/  1  uming  head  to  nght 


l^  %M 


AJU.'. 


Turning  head  to  left     - — 

Attempt  to  overthrow    v^i»yi»-4xw-^^  S  iv^aM^  Ze-iZc. 


LEFT 


To  RIGHT  ^^ 
Amp.  ■^"-o-rf. 
Duration  3v(Sec. 


To  LEFT     < 

Amp. 

Duration    :    Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above, 


Nystagmus  (o-^o^a  ulmTU. 
Vertigo    J^,n,^ 
Past-pointing     — 


■  />JAA>V<tJL^ 


^'—^it^tajJUt. 


To  LEFT 
Shoulder  from  above 


Nystagmus 

Vertigo 

Past-pointing 


to 


to 


Douche  RIGHT  jh 
Amp. 
After  //  min 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  ^(y*^^^^ 
Vertigo    w^  ^-jA*!-^ 
Past-pointing    . — 
Falling    ->^<-t,<..-^- 
Head  Back  i/ajJX^  tJU^,^- 

Amp.   ^a^jZCy  ^jnUAx^^JCi  -«^*x><-:a£i-«- ,  y*UxjulutJL. 

Douche  LEFT  Q^'/^JU.  At^J^Yio\x(.^ie.  LEFT 


Amp. 
After 


min.  vosec. 


Shoulder  from  above 


Head  Back 
Amp.     ^«'um<j-^-»JC 


Nystagmus 
Vertigo 
Past-pointing 
Falling 


to 


to 


to 


to 


to 


344 


EQIILIBRUM  AND  VERTIGO 


tion  whicli  was  ])roiluce(l  was  a  pert'ectlv  normal  rrspunse  so  far  as  tlie  stiiiiulalioii 
from  the  horizontal  canal  itself  was  coucerned.  The  absence  of  the  (piick  com- 
ponent of  the  nystaiinius  would  indicate  a  supranuclear  interference.  The  striking^ 
phenomena  of  this  examination  were  the  absence  of  vertigo  and  the  absence  of  the 


RIGHT 


LEFT 


llo. — Dotted  lines  indicate  location  of  lesion. 


quick  component  of  nystagmus:  both  of  these  phenomena  indicate  a  lesion  at  the 
same  jwint — the  base  of  the  cerebral  crura.  The  impairment  of  vertigo  from  stimu- 
lation of  all  the  canals  would  indicate  a  lesion  at  the  decussation  of  tlie  superior 
cerebellar  peduncles  in  the  base  of  the  cere1)ral  crura  and  the  impairment  of  the 
quick  component  of  nystagmus  would  similarly  indicate  a  lesion  at  the  same  point 
because  of  an  interference  witli  the  impulses  coming-  from  the  cerebrum  to  the  eye- 


PATHOLOGIC  CASES  ANALYZED 


345 


muscle  nuclei.  The  following  report  was  made  in  writing:  "The  results  of  the 
ear  examination  suggest  a  lesion  of  the  upper  portion  of  the  pons  at  the  junction 
of  the  cerebral  crura  at  the  point  where  the  cerebral  fibres  reach  the  region  of  the 


Fig.    116.      (Case  11.)     Glioma  of  the  pon.s. 

posterior  longitudinal  bundles  (Fig.  115).  The  medulla  oblongata  and  the  lower 
half  of  the  pons  appear  uninvolved." 

Autopsy. — Dr.  William  G.  Spiller  made  the  following  report  of  his  macro- 
scopic and  microscopic  examination: 

"The  tumor  extends  from  the  uppermost  portion  of  the  cerebral  peduncles, 
thi'ough  tlie  pons,  and  into  the  left  cerebellai-  lobe.     It  is  confined  to  the  left  half 


340  EQUILIBRIUM  AND  \  ERTIGO 

of  the  brain-stem  throughout.  It  causes  niucli  enlariieuieiit  of  the  left  side  of  the 
cerebral  peduncles,  and  implicates  almost  all  of  this  side.  In  the  upper  part  of  the 
pons  the  posterior  longitudinal  bundle  on  the  right  side  is  well  preserved,  but  the 
outer  portion  of  the  posterior  longitudinal  bundle  on  the  left  side  is  much  de- 
generated. The  tumor  in  the  upper  part  of  the  pons  is  confined  to  the  left  tegmen- 
tum. The  same  is  true  of  the  middle  portion  of  the  pons.  The  tumor  greatly 
compresses  the  IV  ventricle  and  almost  closes  it  by  disi)lacement  of  the  surrounding 
tissue.  It  does  not  invade  the  medulla  oblongata,  l)ut  at  the  level  of  this  structure 
it  is  contined  to  the  white  matter  of  the  left  cerebellar  lobe.  It  is  a  glioma 
(Fig.  116)." 

Comment 

A  study  of  the  data  obtained  by  the  ear-tests  and  necroi)sy  in- 
dicates certain  definite  facts,  as  to  the  vestibular  pathways  in  the 
brain-stem.  Tlie  examination  demonstrated  that  the  tracts  from 
all  the  semicircular  canals  except  the  right  verticals,  through  the 
vestibular  nuclei  to  the  nuclei  of  the  ocular  nerves  were  open. 
The  specimen  showed  that  the  Deiters'  nucleus  group  (Deiters' 
nucleus  proper,  the  triangular  nucleus  and  von  Bechterew's 
nucleus)  was  unaffected  by  the  lesion,  as  were  also  the  entire 
medulla  oblongata  and  the  lower  part  of  the  pons. 

Let  us  recall  the  peculiar  response  of  conjugate  deviation.  This 
ocular  movement  may  be  regarded  as  the  slow  component  of  nys- 
tagmus. For  it  to  occur  it  is  only  necessary  that  the  stimuli  shall 
pass  from  the  ear  through  the  posterior  longitudinal  bundle  to 
the  nuclei  of  the  VI  Xerve  and  of  the  III  Nerve  (or  rather  of  that 
])art  of  this  nerve  which  innervates  the  internal  rectus).  The  con- 
jugate deviation,  therefore,  results  from  stimulation  of  the  ear; 
but  this  normally  is  converted  into  a  nystagmus  by  impulses  from 
the  cerebrum  wdiich  tend  to  call  the  eye  back  to  its  usual  position, 
that  is,  if  the  cerebro-oculo-nuclear  tracts  are  open.  It  follows, 
therefore,  that  if,  as  in  this  case,  the  response  is  only  a  conjugate 
deviation,  some  lesion  is  interfering  with  the  transmission  of  the 
cerebral  stimuli  to  the  nuclei  of  the  ocular  nerves  affected.  It  has 
been  shown  by  necropsy  that  such  a  lesion  was  present. 

It  may  be  of  interest  to  note  in  this  connection  that  one  fully 
anesthetized,  when  the  semicircular  canals  are  stimulated,  shows 
only  a  conjugate  deviation  and  no  return  movement. 


PATHOLOGIC  CASES  ANALYZED  347 

Let  us  turn  now  to  an  explanation  of  the  vertigo  in  the  light 
of  our  preniorteni  and  postmortem  findings.  We  believe  that  the 
ear  stimulus  which  produces  vertigo  passes  to  the  cerebrum 
through  the  cercbclliiDi.  While  the  paths  which  carry  the  vesti- 
bular stimuli  through  the  cerebellum  to  the  cerebrum  are  not  dem- 
onstrated absolutely  in  all  their  extent,  the  facts  at  our  disposal 
appear  to  indicate  that  they  are  received  by  the  cerebellum  through 
the  inferior  cerebellar  peduncle  from  the  horizontal  canals  and 
the  middle  cerebellar  peduncle  from  the  vertical  canals,  and  after 
completing  their  cerebellar  itinerary,  pass  to  the  cerebrum  by  way 
of  the  superior  cerebellar  peduncles.  In  the  present  case,  ear- 
stimulation  failed  to  produce  the  normal  vertigo  from  all  the  semi- 
circular canals  except  the  left  verticals.  Clearly,  therefore,  there 
was  obstruction  somewhere  in  this  vestibulo-cerebello-cerebral 
pathway  concerned  with  the  stimuli  causing  vertigo.  As  there  was 
present  a  conjugate  deviation  from  the  stimulation  of  the  same 
canals  or  tracts,  the  lower  neuraxial  pathways  appeared  open.  To 
explain  this  absence  of  vertigo  the  logical  place  of  destruction  was 
at  the  decussation  of  the  superior  cerebellar  peduncles.  The 
necropsy  studies  showed  involvement  of  the  superior  cerebellar 
peduncles,  which  have  been  demonstrated  to  contain  tracts  which 
pass  to  the  cerebrum  from  the  cerebellum. 

With  regard  to  the  spontaneous  nystagnuis  upward,  this  case 
confirms  our  previous  experience  that  such  a  nystagmus  is  indica- 
tive of  a  brain-stem  lesion,  either  destructive  or  due  to  pressure. 

The  right  vertical  canals  failed  to  produce  any  reactions.  It 
follows,  therefore,  that  the  neuraxial  fibres  from  these  canals  were 
involved,  and  as  the  lesion  was  in  the  upper  portion  of  the  pons, 
that  these  fibres  must  reach  at  least  as  high  as  the  site  of  this 
lesion.  That  the  lesion  extended  further  down  on  the  left  side  sug- 
gests that  the  fibres  from  the  right  vertical  canals  may  decussate 
to  the  opposite  side. 

Case  12. — 'Mr.  C  S.,  age  56.  The  patient  was  admitted  to  the  Hahnemann 
Hospital  October  1,  1916,  complaining'  of  vertigo,  staggering,  projectile  vomiting, 
severe  headache  and  weakness  of  the  lower  extremities,  especially  the  left. 


.U8  EQT  ILIBRIT  M  AXJ3  A'ERTIGO 


CHART  XXV  A 

Name     W.    QJ-  /  H^-    <^^  Date    (Qa/ .  zy,  ^f/C 

Address     v-i^4ua>«^<..  «t.  >c-  <J^i'^^fi-3^C-iZZ^ 

Referred  hy    ^^    i^^^^  ^  ^  £,>.,j:lUr  r    ^-  g^>( 


DIAGNOSIS: 


SUMMARY: 


Compiains  of    V^aZ^^  ,  /zZf^f^.c^^^^a    -a-ix-^     K^^^x^o^c-^jt, 


HISTORY:  . 

Dizziness     v/-<^ 
Staggering    c/t«- 
Deafness     ./^ 
Tinnitus     ,/^ 


NOSE:       Jrjt^AX^^ 
THROAT:     ^^-^-^^ 


EARS:  .    / 

A.  S.   QX^aMA-  /»-t^Zi,<v<.20*v<.  ,    jt^^ZAu^-^^AJ-^K-^ 

Fistula     '^jL^y«-Z*^i'/~t. 


Hearing  TesU  ^  W  OLt^ 

A]/  Al/  Ac    >       Be     =■       n  Pol.  I  c' I 'i^tr'T^'      Galt|/ 

=  I  /.  I   ^  Ac    >       Be     =       n  I  I  -^^,.^^c:l  I ,  p**  — 


PATHOLOGIC  CASES  ANALYZED 


349 


CHART  XXV  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 

POINTING 

RIGHT 

LEFT 

Looking  to  RIGHT     Jht^^ 

Shoulder  from  above 

<^jZ..a^ 

(?/Z.^/.j^ 

Looking  to  LEFT    o4'fvut^ 

J  ^a-C-^^^^La.^'^.'Xl 

y-u.-i^a-o^^.-ef^.^'-oJ-i. 

Nyst 

igmus     v/-<n/\^ 

Looking  UP     J^trv^ 

Vertigo        Ut^ 
Past-pointing     .^tn^Ji^ 

Looking  DOWN    Jl^m^ 

Falling 

Romberg      f-*X^%    t-o^.cJirr.-'y^ 

Turning  head  to  right      x-i^ 

±<.<CZr  4. 

Turning  head  to  left             •< 

■' 

Attempt  to  overthrow           '• 

" 

•JjLuJUk^    a    f-'^tA^aZc.   ^IUAMJ^JC:^    ^ 

TURNING 

'        To  RIGHT    >           ^ 

;       To  RIGHT 

Amp.  UA.KuA.*Ko.tt\j  jL*y\^i 

Duration  3  t  Sec.           ^ 

Shoulder  from  above 

i  9"\.0  I^k'ciIu- 

Nystagmus   a^Afg4A^>^i^ 

Vertigo      -4-o^'i'w.tjL 

Past-pointing  i/y^ti^tjcAA^ii' 

To  LEFT     < 

\\      To  LEFT 

^  ^  ■'  to  G^ 

/O 

Amp.  tu<i'*»f.»jUu  -Ck^i 

Shoulder  from  above 

O^to  /^ 

Duration  J  TSec. 

Nystagmus    jL^^y^yy*'"^^^ 
Vertigo      ./^-.vu...*/. 
Past-pointing  e^<i/«4<*«»^Zi^ 

/F-t  ti^ 

/^■'^     /l^ 

Douche  RIGHT     ^"-^^ 
Amp. 
After  j!^  min.        sec. 


Head  Back    ^ 

Amp.    /yo--d 

Douche  LEFT    Jhrv^jL. 
Amp. 
After  ^  min.        sec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus    ^  M-£«^ 
Vertigo      d**,Z-»<,»-wv»-»t.^ 
Past-pointing         •  < 
Falling 


Douche  LEFT 
Shoulder  from  above 


Nystagmus     -^t^-^amA- 
Vertigo      cy<>i,.^-M,»>k*«<-«>^ 
Past-pointing  -  > 

Falling  ,, 


to 


L-'^o'T^c^Cj 


/O  "to  ''RjJa*^- 


Head  Back     •< 

Amp.    "Vo-t-JL 

From  Dr.  I,  H.  Jones'  Equilibrium  and  Vertigo. 


A  Ji^toAySt  3.^  to  Ai^ 

I 
\ 
Copyright,  1918,  by  J.  B.  Lippincott  Co. 


350  EQUILIBRIUM  AND  ^  ERTIGO 

He  was  in  good  liealth  until  four  years  bet'ore  admission,  at  which  time  he 
nolici'd  that  it  was  becoming  dilticult  for  him  to  walk  in  a  straight  line.  At  about 
the  same  time  he  began  to  have  "dizzy  spells."  As  time  progressed  he  found  that 
while  walking  he  always  veered  toward  the  left.  This  inability  to  walk  straight 
and  the  occasional  attacks  of  vertigo  were  the  only  symptoms  for  the  firet  year  of 
his  illness.  Then,  three  years  ago.  he  began  to  have  the  severe  headaches  which 
have  been  present  almost  constantly  ever  since,  and  at  the  same  time  he  noticed  that 
he  was  getting  blind.  One  year  before  admission  the  attacks  of  vei'tigo  became 
much  more  frecjuent  and  the  staggering  became  so  severe  that  frequently  he  would 
be  unable  to  stand  upright  without  grasping  some  object  for  sujiport. 

The  family  history  and  previous  medical  histoiy  were  negative.  The  following 
notes  of  his  physical  examination  were  made  at  the  hospital:  ''Drooping  of  the 
left  side  of  the  face.  The  grip  is  poor  in  each  hand  and  there  is  considerable  inco- 
ordination of  both  upper  extremities.  Loss  of  power  in  both  lower  extremities, 
more  marked  in  the  left,  and  marked  ataxia  with  a  tendency  to  falling,  especially 
backward.  The  patellar  reflexes  are  normal.  Pupils  react  normally  to  light  and 
accommodation.  Examination  of  the  eye-grounds  show.s  double  choked  disc  with 
dilated  blood-vessels.  The  visual  fields  are  concentrically  contracted.  The  patient's 
mentality  is  poor;  he  answers  questions  slowly  and  does  not  even  kmiw  what 
year  it  is.'' 

The  first  ear-examination  was  made  on  October  16,  1916,  by  Drs.  Palen  and 
Clay.  The  eochleas  were  found  to  be  normal :  the  only  abnormality  in  the  hearing 
was  a  slight  diminution  for  the  lower  tones.  Turning  to  the  right  and  the  left 
each  produced  a  nystagmus  of  35  seconds'  duration;  this  showed  that  the  hori- 
zontal canals  were  not  only  functionating,  but  jDroduced  hyperactive  responses. 
Douching  the  right  ear  jDroduced  responses  after  one  minute  and  thirty  seconds  of 
douching.  Douching  the  left  ear  produced  responses  after  one  minute  and  twenty 
seconds.  This  showed  that  the  responses  from  the  vertical  canals  of  both  sides 
were  present,  although  somewhat  delayed. 

The  i^atient  Avas  examined  by  us  only  nine  days  later  and  yet,  as  the  accom- 
panying chart  (XXV)  shows,  there  had  occurred  marked  changes  in  the  vestibular 
mechanism  in  that  short  time. 

In  interpreting  the  findings  on  the  chart,  it  is  evident  at  a  glance  that  we  are 
dealing  with  a  central  lesion.  The  vertical  canals  of  both  eai-s  show  no  responses, 
whereas  the  horizontal  canal  of  each  ear  shows  hj-peractive  responses  both  to 
turning  and  douching.  The  right  cochlea  is  normal,  the  right  horizontal  canal  is 
functionating  and  yet  the  right  vei'tical  canals  produce  no  responses.  The  same 
phenomenon-complex  is  shown  bj-  the  left  ear.  Therefore  it  would  be  highly  im- 
probable that  the  vertical  canals  of  each  ear  had  become  destroyed  and  it  would  be 
more  reasonable  to  assume  that  the  vertical  canals  fibres  had  become  blocked  intra- 
cranially.  This  view  is  corroborated  in  that  after  turning  to  the  right,  instead 
of  a  clean-cut  nystagmus  to  the  left,  there  is  a  tendency  to  conjugate  deviation  to 
the  right;  similarly  after  turning  to  the  left  there  is  a  tendency  to  conjugate  devia- 
tion to  the  left.     So  far.  therefore,  the  tests  suggest  that  the  lesion  is  central. 

A  more  exact  location  of  the  lesion  is  best  attained  by  first  eliminating  the 
normal  portions  of  the  vestibular  apparatus : 


PATHOLOGIC  CASES  ANALYZED 


351 


(1)  The  labyrinths  and  YIll  Nerves  are  normal,  because  the  hearing  is  unim- 
paired and  the  horizontal  canals  produce  g'ood  responses. 

(2)  The  medulla  oblongata  Avould  appear  normal  because  when  eaeb  horizontal 
canal  is  tested  separately,  by  putting  the  head  back  after  douching,  normal  responses 
appear. 


RIGHT 


LEFT 


TEMfORAL 
LOBE 


— Dotted  line  indicates  location  of  lesion. 


(3)  The  cerebellar  cortex  would  appear  to  be  normal  because  we  were  able 
to  elicit  a  normal  past-pointing  of  both  anns  in  both  directions. 

If  then  we  consider  that  the  labyrinths,  VIII  Nerves,  medulla  oblongata  and 
cerebellar  cortex  are  uninvolved,  it  would  at  first  seem  reasonable  to  decide  that 
the  vertical  canals  fibres  were  involved  in  the  pons.     This,  however,  would  not  seem 


So^Z  EQUILIBRIUM  AND  VERTIGO 

likely  because  when  tlie  jnitieiit  was  examined  only  nine  days  previously  reactions 
from  the  vertical  canals  of  both  ears  were  obtained.  It  would  be  improbable  that 
a  lesion  should  extend  so  far  into  both  sides  of  the  pons  within  these  nine  days;  a 
more  simple  explanation  of  this  phenomenon  would  be  that  there  had  occurred  an 
increase  of  pressure  in  this  region.  The  tendency  to  a  conjugate  deviation  both  to 
the  right  and  to  the  left  indicates  an  interference  with  the  cerebro-ocular  tibres 
at  the  base  of  the  cere])ral  crura,  where  tlie  tibres  from  the  cerebral  hemispliei-es  to 
the  eye-muscle  nuclei  enter  the  posterior  longitudinal  l)undles. 

The  following  report  was  therefore  made: 

"The  ear-tests  suggest  a  tumor  at  the  junction  of  the  anterior  superior  aspect 
of  the  cerebellum  and  the  brain-stem  (Fig.  117).  Speaking  purely  from  the 
standpoint  of  the  ear-tests,  the  tumor  would  appear  to  be  centrally  located  and 
therefore  inoperable.  There  is  no  evidence  to  suggest  that  one  side  is  more  in- 
volved than  the  other.  The  following  appear  normal:  (1)  Labyrinths.  (2)  VIII 
Xenes.  (3)  Medulla  oblongata,  (4)  Posterior  longitudinal  bundles.  (5)  Inferior 
cerebellar  peduncles,  (6)  Cerebellar  cortex  throughout." 

Report  of  autopsy  by  Doctor  Sappington  :  "The  site  of  the  corpora  (|nadri- 
gemina  was  occupied  by  an  oval  tumor  three  inches  by  an  inch  and  a  half  in, size. 
The  corpora  quadrigemina  themselves  were  not  in  evidence,  apparently  being  ob- 
literated by  the  growth.  The  tumor  was  situated  in  the  middle  line  just"  posterior 
to  the  posterior  commissure  and  pineal  body  and  just  anterior  to  the  velum  medularse 
anterius  and  also  just  anterior  to  the  origin  of  the  trochlear  nerves.  The  tumor 
practically  roofs  the  aqueduct  of  Sylvius.  There  were  no  gross  hemorrhages  in  or 
about  the  tumor.  The  tumor  itself  was  about  the  firmness  of  the  cerebral  tissue  and 
on  section  appeared  whitish  gTay  and  in  some  places  was  almost  caseous.  The 
lateral,  the  third  and  the  fourth  ventricles  show  no  gross  changes.  Cerebrum 
normal.  Section  of  the  cerebellum  showed  it  to  be  normal.  Medulla  oblongata, 
pons,  inferior  and  middle  cerebellar  peduncles  were  also  normal." 

We  note  that  the  tumor  was  in  the  exact  spot  suggested  by  the  ear-tests. 

Case  13. — Mr.  E.  B..  age  24.  This  patient  was  a  college  student,  apparently 
in  excellent  health,  and  merely  complaining  of  slight  attacks  of  dizziness.  He 
suffered  very  little  inconvenience  and  regarded  the  matter  lightly;  it  was  only  on 
plying  him  with  questions  that  the  following  details  were  elicited:  One  month 
before  the  ear  examination  he  noticed  that  he  had  some  difficulty  in  keeping  step 
while  he  was  dancing;  this  inco-ordination  seemed  to  be  most  marked  when  he  would 
be  looking  at  the  other  dancers.  He  also  recalled  that,  at  about  the  same  time,  if 
he  moved  his  head  quickly,  it  would  make  him  dizzy.  A  week  later  he  began  to 
stagger  a  little;  when  it  first  came  on,  it  was  so  slight  that  he  was  never  aware  of  it 
himself,  but  was  told  of  it  by  other  people.  Soon,  however,  it  became  so  marked 
that  very  frequently  he  would  have  to  hold  on  to  objects  for  support.  During  these 
attacks  of  staggering  he  would  lean  to  the  right  and  forward  and  had  a  sensation 
of  some  heavy  weight  on  his  head  and  shoulders.  At  no  time  did  he  have  much 
tinnitus;  only  once,  one  week  before  this  examination,  he  noted  a  slight  singing  in 
the  ears. 

The    results    of    the    ear-examination    are    given    on    the    accompanying   chart 


PATHOLOGIC  CASES  ANALYZED  353 

(XXYI).     In  attempting  an  explanation  of  the  findings,  the  following  deductions 
were  made : 

(1)  We  are  dealing  with  an  organic  lesion  and  not  Avith  a  functional  neurosis. 
The  accompanying  vestibular  chart  shows  definitely  impaired  resiDonses — the  result 
of  a  damaged  ear-mechanism. 

(2)  Having  determined  that  there  is  an  organic  lesion  involving  the  ear- 
mechanism,  we  are  led  to  believe  that  this  lesion  is  central  and  not  peripheral  for 
the  following  reasons:  (a)  Perfectly  good  hearing  on  both  sides.  With  intact 
cochleas  it  is  fair  to  assume  that  the  internal  ears  in  their  entii'ety  ai"e  unaffected. 
(&)  The  presence  of  a  spontaneous  vertical  nystagmus,  both  upward  and  down- 
ward ;  this  is  pathognomonic  of  a  central  lesion  and  would  indicate  a  brain-stem  dis- 
turbance, (c)  There  appears  to  be  a  difference  in  the  excursion  of  the  eyes  when 
looking  to  the  left;  this  ineo-ordination  of  ocular  movement  obviously  could  not  be 
produced  by  disturbance  in  the  labyrinths,  (d)  Both  the  turning  and  the  douching 
produced  a  fair  nystagmus,  but  the  past-pointing  for  one  or  the  other  arm  was 
very  poor,  almost  absent  or  in  the  wrong  direction.  Such  a  differentiation  must,  of 
course,  be  central  and  not  peripheral. 

(3)  There  is  no  one  lesion  that  could  account  for  all  of  these  disturbances. 
The  examination  would  therefore  suggest  multiple  lesions  such  as  would  occur  in 
a  case  of  disseminated  sclerosis. 

A  study  of  the  responses  to  the  pointing  tests  shows  that  there  is  an  impair- 
ment in  the  pointing  of  each  ann  outward.  This  was  so  constant  that  it  made 
probable  an  actual  small  lesion  of  the  cerebellum  itself,  rather  than  in  the  path- 
ways on  the  way  to  the  cerebellum.  The  nystagmus  produced  by  stimulating  the 
semicircular  canals  was  abnormal,  but  the  degree  of  impairment  was  different  or 
varied  with  each  canal  stimulated;  this  would  suggest  multiple  lesions  in  the  brain- 
stem. There  is  no  evidence  of  any  large  lesion  an\nvhere,  since  not  a  single  re- 
sponse is  completely  abolished. 

Several  months  later,  July  21,  1916,  this  patient  was  admitted  to  the  Ophthal- 
mologic Department  of  the  University  Hospital  becanse  of  failing  vision.  He  im- 
proved somewhat  and  left  the  hospital.  Two  months  later,  September  21,  1916,  he 
was  readmitted — this  time  to  the  neurologic  service.  He  had  suffered  a  sudden 
change  for  the  worse;  at  this  time  he  was  hardly  able  to  walk.  His  vertigo  was 
veiy  severe,  the  weakness  in  the  legs  was  getting  gradually  worse,  his  speech  had 
become  slurring,  nasal  and  monotonous,  and  he  became  emaciated  and  weak.  The 
folloAving  notes  were  made  by  Dr.  William  G.  Spiller:  "Pupils  equal  and  react 
equally  and  promptly  to  light,  accommodation  and  convergence.  Facial  musculature 
unimpaired.  The  tongue  is  protruded  slightly  to  the  right  of  the  midline  and  is 
freely  movable  to  either  side. 

^'Extremities. — Grip  is  fair  with  the  right  hand,  poor  with  the  left.  There  is 
a  marked  ataxia  of  the  upper  extremities  and  at  times  there  develops  a  gross  in- 
tention tremor  in  both  upper  extremities  on  attempting  the  finger-to-nose  test  and 
the  finger-to-flnger  test.  Adiadokokinesis  is  present  in  both  forearms.  Sense  of 
position  and  stereognostic  sense  are  normal  in  both  hands.  Biceps  jerk  normal 
and  equal  on  both  sides;  triceps  jerk  questionably  present  on  both  sides.  Knee 
jerk  slightly  exaggerated  on  the  right  side,  normal  on  the  left.  Achilles  jerk  mod- 
?3 


354  KQUlLlJiUllM  AND  VERTKJC) 

CHART  XXVI  A 

Address  /^  X     /»  /     '      ' 

Referred  by  ^.^.    /    ^.    ^^ 


DIAGNOSIS: 


SUMMARY: 


Complains  of    2^^</vZ^    ,0,,,^  prXSV^-O*— V  ,  -a^-^- 
HISTORY: 

Dizziness    -^■C  -C^uc-ul^-,    iZkyjZjL  /  ->\,L,tnuX.    *^a. 

Staggering  ./fe  XUl,.^i^ ,    ifZi,zUJL  3  ^       / 

Deafness     .y^^  "^*^^  ^  *-^^  ^ 

Tinnitus      >/^.,^^ 


NOSE:       ^jt^aZ:^ 
THROAT:      ^jt^^aZ::.^ 


EARS:  ^'  '^'   ^^'^  aCCZ.^^^.^^  ,  ^sd^..,.^Ji^    ^cO:^  . 
A.  S.  c^X^-Lf-  /uZ^a-=JZ:^,  o-^^CZ\..,...,Ujl,    y^^CEZ.^^ 

Fistula     yrjLyax>jCiriy 

Hearing  Tasts 

Aj/i  AjJ  Ac     >       Be    <       n  Pol.  |  c^l^^^        Gall  I  -^-^^^ 

'A       '^      Ac  ^    Be  <   n  I  15^^        I        :+: 


PATHOLOGIC  CASES  ANALYZED 


355 


CHART  XXVI  B 


NYSTAGMUS 


Looking  to  RIGHT 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


POINTING 


RIGHT 


Shoulder  from  above 

Looking  to  LEFT    5^ 

MAiJtjJ ,  A^ikAt^  Nystagmus    1^  ***^  t^oU<yCt-r>r, 

Looking  UP      T  Vertigo  tt-ryu- 

'»<**^^^  Past-pointing    «*>v«_ 

Looking  DOWN     ^  Falling  y^-r***-  y 

•)>,j„jMju)L  Romberg     <m^-»->^  "^  ^  T"-^ 

Turning  head  to  right  «i^  ~-^   »-«=-<t^*^  "'**^?^ 

(»»*yK.,^  r^A^e^^i'^^^     Turning  head  to  left         ••         ' 

/     /  Attempt  to  overthrow     yi^  ^iiiZi^ 


LEFT 


To  RIGHT 


Amp.  J.v*^.  o»/n^- 
Duration  /-/Sec. 


TURNING 


To  RIGHT 
Shoulder  from  above 


Nystagmus  t^>tA^,»<^»-r 
Vertigo    Ji-j,^oj.^..ejL 
Past-pointing   vY^*"-*-^-"-"*^ 


To  LEFT    -^ — 

Amp.  ^t.-»-«^  -  '^ 
Duration  »?f  Sec. 


/..x.^*-,'. 


To  LEFr 
Shoulder  from  above 


Nystagmus  '-^z 
Vertigo   ^. 
Past-pointing  J-irntx^n*^ 


Douche  RIGHT    ^^ 
Amp.  "?•■»-»- 
After    A  min.  /.J"  sec. 


Head  Back  °u^1cIU-a^ 
Amp.  (/ 

Douche  LEFT    1^ 
Amp.  'v'-<»-'--r 
After    /   min.  3o  sec. 


Head  Back   « — 
Amp.  -^^^.^ 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 

Nystagmus  ^*«  -^ 
Vertigo  <^UvT.A.«-cf^  'jj^ixamJL 
Past-pointing  ;?)K»AA.t-«t^  -u^^ay^/u.^ 
Falling    JIUaaJ. 


Douche  LE  rr 
Shoulder  from  above 


Nystagmus    '-o-^^ 
Vertigo   W^^^^m^ 
Past-pointing   )? 
Falling    !^xtAw<. 


;!^:C-<uCtX 


<i-io^ 


(s>'Xo'R'^i^ 


3oG  P:QriLlBRll  M  AND  VERTIGO 

erate  and  equal  ou  both  sides.  Ankle-clonus  obtained  on  the  right  side  on  the  first 
examination,  but  cannot  be  elicited  on  either  side  on  the  second  examination.  Heel- 
to-knee  test  shows  marked  ataxia  on  both  sides.  Both  lower  extremities  and  trunk 
are  ataxic.  He  cannot  stand  or  even  sit  up  unsupi^orted.  There  is  more  power  in 
extension  of  the  knees  than  in  Hexion.  There  are  frequent  and  rapid  changes  in 
amount  of  power  of  all  tiie  movements  of  the  extremities.  Sense  of  touch  and 
pain  normal  throughout.  Cremasteric  reflex  prompt  on  the  left  side,  but  sluggish 
on  the  right. 

Eye  examination  hy  Dr.  cle  Schiceinitz  on  September  26,  1916.  show^ed  a 
marked  paling  of  the  upper  half  of  the  optic  nei-ve  on  each  side  and  a  paralysis 
of  the  right  internal  rectus. 

A  Wassermann  of  the  blood  was  repeatedly  negative. 

An  examination  of  the  urine,  the  lung-s  and  heart  was  negative. 

On  October  10,  1916.  it  was  noted  that  the  patient  was  a  little  flighty  and  had 
delusions. 

He  died  suddenly  on  December  21.  1916. 

Autopsy  by  Dr.  "William  G.  Spiller:  ''Brain  substance  has  a  finn.  dense  feel. 
Arteries  of  the  base  show  no  fibrosis.  The  lateral  ventricles  are  distended  and 
remain  rigidlj'  extended  even  when  incised,  suggesting  a  special  firmness  of  the 
surrounding  In-ain  substance."  Histologic  examination  showed  typical  changes  of 
multiple  sclerosis  throughout  brain  and  spinal  cord. 

Comment 

It  is  to  be  noted  that  when  this  young  student  first  presented 
himself  he  was  in  excellent  general  health,  except  for  slight  ver- 
tigo. It  is  from  such  cases  as  this  that  we  learn  how  serious  may 
be  the  significance  of  even  a  slight  dizziness;  this  case  also  em- 
phasizes that  regardless  of  the  general  health  of  the  patient,  a 
well-developed  spontaneous  vertical  nystagmus  indicates  a  serious 
intracranial  disturbance  and  the  prognosis  in  such  conditions 
should  always  be  guarded.  At  the  time  of  the  original  ear-exami- 
nation, we  were  so  impressed  with  the  serious  possibilities  in  this 
case  that  moving  pictures  were  taken  of  his  resjoonses  to  ear-stimu- 
lation as  well  as  of  the  spontaneous  vertical  nystagmus  upward 
and  downward.  It  is  important  to  note  that  the  ear-examination 
in  this  case  gave  definite  information  in  regard  to  the  nature  of  his 
disease  very  early  in  its  development.  The  autopsy  corroborated 
the  evidence  furnished  by  the  original  ear-examination. 

Case  14. — Stei^hen  F.,  age  12.  This  patient  was  refen-ed  for  an  ear  exami- 
nation with  a  provisional  diagnosis  of  cerebellar  tumor.     The  patient  was  admitted 


PATHOLOGIC  CASES  ANALYZED  357 

to  the  hospital  of  the  University  of  Pennsjdvania  on  November  4,  1914,  with  the 
chief  conii)laint  of  headache,  vomiting  and  fever. 

Patient  was  well  until  one  month  before  admission,  when  he  began  to  have 
headache,  fever  and  vomiting.  The  patient  has  not  vomited  within  the  last  week. 
During  the  first  week  of  his  illness  he  had  a  slight  rise  of  temperature  and'  was 
markedly  prostrated.  No  convulsions  or  diarrhoea.  During  the  past  week  there  was 
an  evening  rise  of  temperature  associated  with  sweats.  The  headaches  were  always 
worse  at  night.    Patient  cries  with  jjain  in  his  neck  and  side. 

Physical  examination.  Slight  tache  and  Kernig's  present.  Spinal  fluid  clear, 
but  under  great  pressure.  Patient  has  a  tendency  to  walk  to  the  left  and  carries  his 
head  to  the  left.  Biceps  jerks  veiy  slight.  Knee  jerks  absent.  Achilles  prompt. 
No  Babinski  or  ankle  clonus. 

On  the  day  following  admission  to  the  hospital  the  boy  vomited  several  times 
in  the  morning;  at  11  a.m.  he  had  a  peculiar  attack,  during  which,  he  later  said,  he 
was  blind.  There  was  flexion  of  the  arms,  hands  were  flexed  at  the  wrist  and  the 
fingers  held  stiff  and  drawn  together.  This  convulsive  seizure  disappeared  promptly 
on  the  right  side,  but  persisted  for  45  minutes  on  the  left  side.  During  the  attack 
he  vomited  and  complained  of  severe  headache.  A  lumbar  puncture  taken  during 
the  attack  showed  the  spinal  fluid  under  great  pressure.  Patient  was  examined  by 
a  neurologist  the  day  following,  who  reported  as  follows:  "Adiadokokinesis  more 
marked  in  the  left  hand;  in  the  flnger-to-nose  test  the  left  hand  overshoots;  left 
heel-to-heel  test  shows  some  awkwardness.  Towards  the  end  of  a  general  move- 
ment the  patient  executes  two  or  three  movements  of  small  amplitude.  Loss  of 
knee  jerks.  Achilles  present.  Disturbance  of  associated  ocular  movements  to  left. 
In  walking  patient  has  a  tendency  to  lean  forward  and  to  left.  Siabtentorial  de- 
compression advised." 

Two  weeks  later  patient  developed  a  partial  paralysis  of  the  left  external 
rectus,  also  marked  rigidity  of  the  neck. 

Eye-examination  revealed  a  high  grade  choked  disc  in  both  eyes. 

Wassennann  reaction  was  negative. 

The  first  examination  of  his  vestibular  apparatus  was  made  on  November  4, 
1914,  and  the  findings  recorded  on  the  accompanying  chart   (XXVII). 

It  will  be  noted  on  the  chart  that  the  hearing  of  both  ears  was  entirely  normal 
and  that  the  vestibular  apparatus  responded  quickly  and  coiTectly  to  all  the  tests. 
The  nystagmus  was  of  good  amplitude  and  appeared  promptly  after  both  turning 
and  douching;  the  past-pointing  also  after  each  form  of  ear-stimiUation  Avas  nor- 
mal. The  ear  report  was :  "The  normal  responses  in  nystagmus,  vertigo,  past-point- 
ing and  falling,  after  the  turning  and  douching  tests,  would  suggest  normal  laby- 
rinths. YIII  Nerves,  medulla  oblongata,  pons  and  cerebellum." 

Two  weeks  later  another  ear-examination  was  made,  which  showed  startling 
changes  in  the  responses  (Chart  XXVIII).  Just  as  before,  the  patient  showed  a 
normal  nystagmus  and  past-pointing  after  turning,  but  douching  each  ear  with  the 
head  upright,  stimulating  the  vertical  canals,  produced  no  responses  whatever.  The 
douching  was  continuous  for  4  minutes  in  the  right  ear  and  for  5  minutes  in  the 
left.  After  douching  the  left  ear  with  the  head  upright,  the  patient  was  taken 
from  the  chair  and  put  back  on  the  stretcher.     Immediately  the  patient  exclaimed 


358  EQUILIBRIUM  AND  VERTIGO 


CHART  XXVII  A 


Address  -  / 


Nan 

Add 

Referred  l>y 


DUGNOSIS: 


SUMMARY: 


Complains  of  v^K-«!t-<^<»-«-^ ,  V*a-^o4^    MttS^^Zi^     ^!^«.,v„c,t4-c-<.<^  «.^ 


HISTORY:  . 

Dizziness  --^*-'4' 

Staggering  ^4^ 

Deafness  *)^ 

Tinnitus  ^« 


NOSE:  ^x^aCC^ 

THROAT:     *^ 


A.  D.    .^o^u.-..*^ 


EARS: 

A.  S.         Jh,yA^»jL 


Fistula 


~4^jU»»ZC>rl 


Hearing  Tests 


ji4^ty 


Aj3  K\l  Ac     >       Be    =       n  Poll-  cM^^        Gait  |  -  /         ^ 

I3  If  Ac    >       Be    =       n  L  |>^_^  l.y  -^ 


PATHOLOGIC  CASES  ANALYZED 


359 


CHART  XXVII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 
Looking  to  RIGHT    .  ^*a<^ 
Looking  to  LEFT  Jt,,^,^ 
Looking  UP     ^r»nt/i^ 
Looking  DOWN  J^^v^^ 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus    ^irv^ 
Vertigo     J(<^ 
Past-pointing    ./^»-w<.<^ 
Palling 

Romberg     -^^<i23«-^ 

Turning  head  (o  right   ^'  e^^*^^^ 

Turning  head  to  left    Jho    *.t^au>M^  . 

Attempt  to  overthrow  S-L-^lU^  Vt-^a^it^    <^  ^i/o--c,  ^a  *<^^ 


LEFT 


To  RIGHT 


Amp.  V*-^*t 
Duration  3  o  Sec. 


To  LEFT  ^ 

Amp.  "^tmrd. 
Duration  iZ  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus  yh-r^"^"^^ 
Vertigo  -.y-.*.'!**^.*^ 
Past-pointing  »/^>ji*a.a^ 


To  LEFT 
Shoulder  from  above 


Nystagmus.  ^->-u..*<s^ 
Vertigo    J-^^u,^ 
Past-pointing    Jh^^iAA,^^^ 


cf"  to1(;-)ir  S'toJ^if^^- 


/i-to^f^/  /yio/x/i 


Douche  RIGHT    ^^ 

Amp.    ■\Cv-^ 

After        min.  wTo  jcc. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Head  Back 
Amp. 


Nystagmus  -^/Vv*"*^ 
Vertigo   ^.*A,-<-a£ 
Past-pointing  »/^>^u-»-o-^ 
Falling  ^...w*.*,^ 


Douche  LEFT     O 
Amp.  'So-r^ 
After         min.y.^ec. 


Douche  LEFT- 
Shoulder  from  above 


Head  Back    ^M-    tiJu^ 
Amp. 


Nystagmus     j}-.r/iAM.^^ 
Vertigo    J}'»\u.^ 
Past-pointing    J\r^xux^ 


If.-  to^l/'Vno  f^cjUc.. 


^"  Ko^xp 


to 


t^- 


to  4^ 


360 


EQUILIBRIUM  AND  VERTIGO 


CHART  XXVIII 


O;)^^,,^:^^^^ '^^////f//f //TESTS  OF  THE  VESTIBULAR  AIM\\RA  j^     W-f^tMi    laX^ 

SP0NTANE0L5 


Shoulder  from  above 


NYSTAGMUS 

Looking  to  RIGHT"'  ^1.°'^^^ 

Looking  to  LEFT    ^^i*^ 

.  Nystagmus    -  /Vvt^ 

Looking  UP    «y/Vv.»-*'  Vertigo     o^t^i/ 

I.  Past-pointing    ^/^^>i-i/- 

Looking  DOWN    Jr^n^  Falling 

Romberg    v/r.^<i,2w. 
^  .  .^  .  Turning  head  to  right    ^  /  o-^   xl^XZift- 

/^L/M..*^  .^^    A^L^xx-^i^.  Turning  head  to  left     .f^    Z2c22^ 

A/t^ft^^  ,  Attempt  to  overthrow  Jy^  JttAXi^ 


POINTING 
RIGHT     :  LEFT 


To  RIGHT    — > 

Amp.   A.awr-f^. 

Duration  ^3  Sec. 

To  LEFT      < 

Amp.  \-ayi^i- 
Duration   2?  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmu,?     j^it-Kx^ 
Vertigo    -^■v'L-^^^i.aJt 
Past-pointing    Ji-<^^i^aJL 


To  LEFT 

Shoulder  from  above 


Nystagmus   y^rt-c-u^ 
Vertigo   Jt.,^u.,Aj)jt 
Past-pointing  •  i/)-,.ktx,»*<«-^ 


/^"to%/i^S="to^^ 


'^■■to>G/< 


/J"to  ^<^. 


Douche  RIGHT    ^-^-<, 
Amp. 
After  i/-  min.        sec 


Head  Back    — ^ 

Amp.  ^^ly  ^*^« 

Douche  LEFT  -^-»w4. 
Amp. 
After  t5~  niin-        se( 


Head  Back    <; 

Amp.  Uijyj  JLaao^, 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  ^  ^■<-<-'^ 
Vertigo    j1  i'tAy^ 
Past-pointing    ^4  ^t^t**^ 
Falling  ^/<,a*^ 


7vl-&^t-«^««^      A^-^XZc^t 


Douche  LEFT 
Shoulder  from  above 


Nystagmus   i-Yt-M^^-^ 
Vertigo    ^  l^u^^ 
Past-pointing     -J^  L-cA-i*/- 
Falling    ^  Ua^<^ 


^ilaMj^ 


A>-oOC^ff 


QuZ^l^ 


ur 


6"t„y^,/^. 


PATHOLOGIC  CASES  ANALYZED  361 

that  he  was  very  dizzy  and  it  was  noted  that  a  large  horizontal  nystagmus  to  the 
right  ai^peared.  The  past-pointing  was  immediately  undertaken,  and,  whereas  there 
had  been  no  past-pointing  when  he  w^as  sitting  with  the  head  upright,  now  there 
appeared  a  large  jaast-pointing  of  each  arm  in  a  proper  direction — to  the  left.  The 
right  ear  was  then  douched  again  with  the  head  upright  without  eliciting  any  re- 
sponse, and  then  quickly  the  head  was  i^ut  backwards.  Immediately  the  normal 
nystagmus,  vertigo  and  past-pointing  appeared. 

Comment 

This  ix'culiar  phenomenon  of  loss  of  responses  from  the  verti- 
cal semicircular  canals  of  each  ear  appearing  under  our  own  ob- 
servation within  the  past  two  weeks  was  difficult  to  explain.  We 
had  never  observed  it  before.  We  were  simply  confronted  with 
the  fact  that  suddenly  the  vertical  semicircular  canals  had  ceased 
to  react.  This  failure  of  reaction  could  be  explained  either  by  a 
disturbance  within  the  canals  themselves  or  along  their  pathways. 
The  hearing  in  this  case  being  normal  and  the  horizontal  canals 
responding  normally  to  stimulation,  it  was  difficult  to  conceive  of 
a  lesion  that  would  pick  out  only  the  vertical  semicircular  canals 
on  each  side  and  leave  the  rest  of  the  labyrinth  intact.  It  would 
similarly  be  difficult  to  conceive  a  lesion  capable  of  destroying  the 
vertical  semicircular  canals  fibres  within  the  VIII  Nerve  and 
leave  the  rest  of  that  nerve  intact.  This  disturbance,  therefore, 
must  be  within  the  brain-stem  between  the  point  of  entrance  of  the 
VIII  Nerve  into  the  brain- stem  and  the  III  and  IV  cranial  nuclei. 
Remembering  that  the  horizontal  canals  on  each  side  gave  per- 
fectly normal  responses,  this  case  made  it  evident  that  there  was 
a  central  neuraxial  differentiation  between  the  fibres  of  the  hori- 
zontal and  vertical  semicircular  canals.  The  horizontal  semi- 
circular canal  fibres  have  been  traced  histologically  to  Deiters' 
nucleus  in  the  medulla  oblongata.  It  appears  probable,  therefore, 
that  the  fibres  from  the  vertical  semicircular  canals  ascend  to  a 
higher  level  and  are  distributed  within  the  pons.  This  sudden  in- 
terference with  the  function  of  the  vertical  semicircular  canals 
fibres  of  both  sides  could  hardly  be  attributed  to  a  lesion  growing 
into  and  involving  both  sides  of  the  pons.  The  most  probable 
explanation  appears  to  be  an  increase  of  pressure  within  the  IV 


362  EQUILIBRIUM  AND  VERTIGO 


CHART  XXIX  A 


Name  ^:i^  ^.  Age  3f  Date  /^r^'Vr. 

Referred  by  OtJi^    A)  jUJiju^^a^ojuj    LtMAr\A^<itZu    -^'f-r^-^jtiJ,  ,    J' k^r^  Mtf^£^\ 


Address 


DIAGNOSIS: 


SUMMARY: 


Complains 


i„,of   M-^J^-^d^ 


HISTORY 


KY :  ~,     ,  -9  I- 

Dirziness     SJ^U-  -.--t  ^aa^i^^a.^ 

Staggering  yArv^  . 

Deafness    J.,^ouMt^  <*«a**4^  ,  Ju^aJU^ 

Tinnitus    Jh^.  '' 


NOSE:      ^^t^XZu^ 
THROAT-     -^>^^«v2I^ 


EARS:  ^ 

A.  S.   ►y/i^u.x-.fc^ 


Fistula 


HeanngTesU       ^  V  £— -  )j).L<^    ) 

A|0  A|A  Ac    <      He    =      n  Pol.  | +•  f        cM  ^-— -       Gait  ^(^^^^ 

=  I  ^  I  /i  Ac     >      Be     =-      n  ■    I  -  I  *^»*«/  I 


PATHOLOGIC  CASES  ANALYZED 


363 


CHART  XXIX  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT  4)/^-^ 
Looking  to  LEFT  ^^^  " 
Looking  UP   v^v^-t 
Looking  DOWN  A.^*.Jt^ 


SPONTANEOUS 


Shoulder  from  above 


Nystagmus  ^j^-^^^ 
Vertigo   ■A'-*^  .CZU-c 
Past-pointing  ^^aZ-^-t 
Falling    ^.rwt 

Romberg     -//jt«<x/ZI.-c 

Turning  head  t6  right   ^"^  AMt-a^.'^^ii 

Turning  head  to  left      xA'o  .«-i*i-»-y,.tA^Jw. 

Attempt  to  overthrow    \j>^  ^JLcC-^ 


POINTING 


RIGHT 


LEFT 


To  RIGHT^—-^ 
Amp.  %cxaa. 
Duration  /PSec. 


To  LEFT    <: 

Amp.  ^f^ow*^ 
Duration  /^Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


y#i44X«<i!     ^^ko>-i^<J^Ji'^ 


Nystagmus 


'/:»^ 


Vertigo   Tk-^aJl*^^  jujuJboju'iJtJ. 

Past-pointing  \^ iAA.*<J -■ 


To  LEFT 
Shoulder  from  above 


Nystagmus   ^^<»-«A» 

Vertigo     Hi-  At-c*»c-»^,   */r»AAAA-aX' 

Past-pointing  (/iuAjuU    i^    e.l*^iIL,ut^U 


/J-to<^ 


Alt 


to    ^^ 


,xi-»<t.     jL»y^.M^.       /»v..e-t»^ 


Douche  RIGHT 
Amp.  ^t-oi—i- 
After   ^  min.        sec. 


Head  Back 
Amp.  K'- 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  -^  i-^^UJ- 
Vertigo   r??  L<a^uX. 
Past-pointing   ^'L*AjuX 
Falling     JIUa^U 


Douche  LEFT    <0 

.\mp.  TBaAX-'Y  -^  ;fc;JS^ 
After    /    min.  3v^sec. 

Head  Back 


^XaX^ 


11    Douche  LEFT 

Shoulder  from  above 

Nystagmus  .^^i^-^^^  Ut^^ 
Vertigo  ~/Vn»>-e 
Past-pointing   -VV>».t- 
Falling    »^.,^,.«, 


Amp.  /^a 


<»'*^-<. 


yyXiAji 


^- to  C/i- 


J"to/^ 


364  EQUILIBRIUM  AND  VERTIGO 

ventricle,  tliis  pressure  interfering  with  tlie  function  of  tlie  ver- 
tical canals  fibres  in  its  floor. 

A  bilateral  subtentorial  decompression  was  performed  on  No- 
vember 19,  1914,  and  the  surgeon's  report  reads:  ''The  cortex  of 
both  cerebellar  hemispheres  appeared  to  be  normal,  except  per- 
haps that  the  meninges  appear  a  trifle  injected.  There  was,  how- 
ever, no  sign  of  a  tubercular  deposit  nor  of  any  tubercles  either 
on  the  cerebellar  hemispheres  or  on  the  meninges.  There  was  no 
evidence  of  tumor." 

Autopsy  was  refused,  but  the  clinical  picture  was  one  of 
undoubted  meningitis. 

Case  15. — Mr.  Fred  L.,  ag'e  30.  Presented  himself  to  the  ear  dispensai'v  of 
the  Hospital  of  the  University  of  Pennsylvania  on  December  10,  1915 ;  he  had  been 
suffering  with  severe  lieadaehes  and  wanted  to  ascertain  whether  some  previous  ear 
operations  that  he  had  had  were  in  any  way  responsible  for  the  headaches.  His 
right  ear  has  been  operated  on  seven  times — the  last  time  tw^elve  years  ago.  Follow- 
ing this  last  operation  he  had  no  trouble  until  two  weeks  ago,  when  he  had  a  convul- 
sion,'which  came  on  so  suddenly  that  he  had  no  recollection  of  it.  He  was  taken  to 
the  Medico-Chirurgical  Hospital  in  an  ambulance  in  an  unconscious  condition.  The 
following  day  he  recovered  consciousness,  but  had  another  convulsion  two  days  later 
while  in  the  hospital.  Four  days  later,  however,  he  felt  perfectly  well  and  insisted 
on  leaving  the  hospital.  He  remained  well  except  for  an  occasional  pain  in  the 
head,  which,  however,  was  very  severe  while  it  lasted. 

When  he  appeared  at  the  dispensary  he  presented  a  picture  of  a  normal, 
healthy  man.  The  accompanying  chart  (XXIX)  gives  the  data  of  the  ear  examina- 
tion at  this  time.  We  note  that  the  right  or  operated  ear  shows  impaired  hearing; 
this  deafness  however,  is  of  the  obstructive  tyjie  and  the  cochlea  is  ai)parently 
functionating.  The  hearing  in  the  left  ear  is  normal.  Turning  to  the  right  shows 
a  marked  contrast  between  the  nystagmus  and  the  past -pointing.  The  caloric  test 
shows  an  absence  of  responses  on  stimulation  of  the  vertical  canals  of  both  ears. 
The  right  horizontal  canal  shows  a  normal  nystagmus,  but  an  absence  of  past- 
pointing.     The  left  honzontal  canal  produces  normal  responses. 

These  impaired  or  absent  responses  evidently  indicated  an  organic  lesion  of 
some  sort.  Further,  the  ear  examination  suggested  a  central  lesion  because  the 
cochleas  were  normal  and  each  horizontal  semicircular  canal  gave  at  least  one 
normal  resjjonse.  The  absence  of  responses  from  the  vertical  semicircular  canals 
of  both  ears  could  not  be  accounted  for  by  a  lesion  either  within  the  labyrintlis  or 
in  the  VIII  Nerves,  but  indicated  an  interruption  along  their  intracranial  jiath- 
ways  within  the  pons.  The  impaii'cd  vertigo  from  the  right  horizontal  canal  prol)- 
ably  indicated  a  disturbance  in  the  region  of  the  right  inferior  cerebellar  jieduncle. 
The  report  of  the  ear  examination  was  as  follows :  "There  is  evidence  of  jiressure 
within  tlie  IV  ventricle.  In  view  of  the  histoiy  of  so  many  ear  operations,  these 
findings  would  indicate  that  the  patient  is  in  a  serious  condition."     This  rei)ort  was 


PATHOLOGIC  CASES  ANALYZED  365 

made  with  some  misgiviug,  because  of  the  apparent  g-ood  liealth  of  the  patient. 
The  patient  was  advised  to  enter  the  hospital;  this  advice  was  not  followed  and 
the  patient  went  home.  Six  days  after  this  examination  the  patient  had  another 
convulsion  associated  with  unconsciousness  and  was  rushed  to  the  University  Hos- 
pital in  the  ambulance.  The  following  day  he  regained  consciousness  and  appeared 
normal  again,  except  that  he  complained  of  an  agonizing  headache.  The  patient's 
gi-ip  was  very  good  and  equal  in  both  hands.  There  was  no  loss  of  power  in  either 
lower  exti-emity.  Sensation  to  touch  and  pain  was  normal  throughout  the  entire 
body.  Fulfils  were  equal  and  responded  normally  to  light,  accommodation  and  con- 
vergence— in  fact,  careful  neurologic  examination  failed  to  reveal  any  signs  of 
intracranial  mischief. 

The  right  ear — the  one  that  had  had  so  many  operations — was  again  operated 
on  by  Dr.  B.  Alexander  Randall  and  nothing  definite  was  discovered  beyond  dimin- 
ished pulsation  of  the  dura.  There  was  no  evidence  of  extra-dural  or  intra-dui\il 
abscess.  Following  this  operation  the  patient  Avas  very  restless  and  entirely  un- 
manageable. It  was  recalled  that  at  the  time  of  the  operation  twelve  years  ago 
when  this  patient  was  in  the  same  hospital  and  operated  on  also  by  Doctor  Randall, 
he  was  equally  unmanageable.  This  aj^j^eared  to  strengthen  the  genei'al  consensus 
of  oiDinion  that  they  were  dealing  with  a  functional  ease.  It  was  difficult  to  con- 
ceive of  anj'thing  except  hysteria  which  could  account  for  these  sudden  and  pro- 
longed attacks  of  unconsciousness  with  convulsions,  from  which  the  patient  would 
emerge  apparently  well  the  following  day.  Lumbar  puncture  had  proven  negative, 
but  two  days  after  the  operation  when  it  was  repeated,  30  c.c.  of  a  turbid  cerebro- 
spinal fluid  was  withdrawn.  Microscopic  examination  of  this  fluid  revealed  an 
intracellular  diiDlococcus.  There  also  occurred  a  rise  of  temperature  with  leueocy- 
tosis.  Very  suddenly  there  appeared  a  spontaneous  vertical  nystagiuus  downward, 
associated  Avith  an  occasional  horizontal  nystagmus  to  the  right.  The  patient  died 
on  the  thirteenth  day  after  admission  to  the  hospital.  The  post-mortem  examina- 
tion revealed  a  large  collection  of  pus  filling  the  IV  ventricle,  which  had  apparently 
reached  there  through  the  aqueduct  of  Sylvius  from  the  III  and  lateral  ventricles, 
which  were  filled  with  pus  from  a  ruptured  abscess  in  the  right  tempero-sphenoidal 
lobe.  This  abscess  had  communicated  with  the  tegmen  by  a  tiny  pin-hole  opening 
for  a  distance  of  about  half  an  inch. 

Case  16. — Edgar  S.,  age  16.  The  patient  was  admitted  to  the  Medico-Chi- 
rurgieal  Hospital  November  5,  1914,  with  the  following  histoiy :  He  was  apparently 
in  perfect  health  until  three  months  ago,  Avhen  he  began  to  complain  of  morning 
headaches.  Coincident  with  the  headache  there  appeared  occasional  double  vision. 
His  sight  began  to  fail  and  for  the  past  three  weeks  he  has  been  practically  blind. 

The  following  are  the  notes  of  the  examination  made  at  the  hospital :  "The 
patient  stands  with  feet  wide  apart.  Station  somewhat  uncertain,  with  a  tendency 
to  fall  to  the  left.  Gait  is  fair,  with  a  tendency  to  walk  to  the  left.  Pupils  are 
widely  dilated.  No  demonstrable  paralysis  of  the  extraocular  muscles.  Opens  and 
closes  eyes  equally  well.  No  weakness  in  the  distribution  of  the  facial  nerves.  No 
weakness  of  the  muscles  of  mastication.  No  loss  of  power  of  the  upper  or  lower 
extremities.     Knee  jerks  absent.     Achilles  jerks  present.     In  attempting  to  touch 


366  EQUILIBRIUM  AND  VERTIGO 


CHART  XXX  A 


Name    GtiLe<xA^   0 .  Age    /to  Date    ^^/^Y/'f/'A. 


Address' 


Referred  by   Q.  ^^.^^    ^ 


DUGNOSIS: 
SUMMARY: 


Complains  of   ^OM^A>,£^AA^t<y ^    (itZaa,^/u^a    -o>u^  ^«.A«-a..«.x-»vCa£    *-t*Z!«^ 


HISTORY 


Dizziness    VfrtA.t'vJ'  ..nJLo    ^r*^---   ^    ^^.-■H^^t,  *^    )Ct«^  ^i^wjut/jLj      -^jL,  <'^^*<^»<A~'»Zid-    pu*-^^ 
Staggering    yc«x  '  '  Jt.«*»<A«,. 

Deafness    v^ 
Tinnitus    ^/^ 


NOSE:  S.^^  ..^^  ^  ^.^^./^^^.    ofA-  ^..,_  ..^  /^  ^><V^  ^  . 
THROAT:   W^vut^  ''^*^«^ 

A.  p.   tOAAAM^  -uJ-ei^    Irfjtyti/    Tfa-^v-d-X^  —  ><-»>u*ca^ 
EARS:       '   ex  y  ' 

Fbtula     JrjL-^^J^Ztfi^ 

Hearing  TesU  -,  »/  /         >-  -77     y-- 

A|i  A  I-/  Ac     ■=     Be    =^     n  Pol.  I  cM '^'-►^      Gait  I     irU^  fi  K'JjVr, 

I'/i.  I  ^  Ac       >        Be       =:        D  I  I  -S*-*^  I 


PATHOLOGIC  CASES  ANALYZED 


367 


CHART  XXX  B 


NYSTAGMUS' 
Looking  to  RIGHT  < 
Looking  to  LEFT  — 
Looking  UP  ->Av«^^ 
Looking  DOWN  »^- 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


POINTING 


Shoulder  from  above 


Nystagmus  iOrt/K-.*/,  J-o^a^v 
Vertigo     J};^^ 
Past-pointing    v^-irw^c- 

Falling      ~y4-<r„JL, 

Romberg      Stn^Ajt-  A.<*f-c^,tyij~a 
Turning  head  to  right   .t/JUA^  ^u^j^  ^^ 
Turning  head  to  left 
Attempt  to  overthrow    X«^    :^J.^XJLtjL 


RIGHT 


£-»Juu>Lq     /5    /^ 


A^f^^^'j^ 


LEFf 


To  RIGHT    >. 

Amp.  K.(XA'*^, 
Duration  3  o  Sec. 


To  LEFT    < 

Amp.  Aajv 
Duration  3jrSec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    t-Aa^eA^E^ 
Vertigo  Jf^ojuu^ 
Past-pointing   v/id!,.i2lLt<t 


To  LEFT 

Shoulder  from  above 


cr'"to1(.y£i 


Nystagmus  d-^t^  Q  cla/Z^ 

Vertigo    «'>wy(a***-<< 

Past-pointing  -^-ttx*,^  rt  ^"-Xt-  -<»a..*c    t^  K*^' 


y-  to/\^    (v^i:uJitJL 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Douche  RIGHT    -^ 

Amp.  ^o-m^ 

After        min.  3o  sec. 

Nystagmus 

Vertigo 

Past-pointing    ^JU.^,*,^   ■ajLt_t.,jU 

Falling     ./fJU,^.,^^.  -  .mjLtjL,jU.  - , 
Head  Back     ^.-t  tUt^jL 
Amp. 


:? "  to^^6- 


Douche  LEFT     i*^ 

Amp.  ^viM,  giLtruj- 
After   /    min.        sec. 


Douche  LEtT 
Shoulder  from  above 


Head  Back   ^^  tUJi^ 
Amp. 


Nystagmus  -^-•'Ux^iZ. 
Vertigo    (^Xl,,.4-x-•-^•<*•-<>-^ 
Past-pointing  .^(i-ot.^    Af-d^ 
Falling  Ki^U^uU-  ' 


J  "  to/^ 


^'^S^ 


(:^a;:uJUjl, 


368  EQUILIBRIUM  AND  VERTIGO 

the  end  of  the  nose  with  the  left  index  finger  tliere  is  a  tendency  to  point  to  the 
left.  Tliere  is  adiadokokinesis  of  tlie  left  arm.  In  attempting*  to  put  the  left  heel 
on  the  right  knee  he  touches  a  point  above  the  knee.  Flexing-  and  extending  the 
left  thig'h  on  the  body  is  somewhat  more  jerky  than  on  the  right.  INIovements  of 
the  trunk  are  well  performed." 

Subsequent  examination  showed  an  improvement  in  these  iindiugs,  and  the  fol- 
lowing notes  were  dictated:  "Finger-to-nose  test  seems  to  be  better  performed  by 
the  left  hand  than  at  the  previous  examination.  The  rotation  of  the  left  arm  is 
better  jierformed  than  at  first — less  marked  adiadokokinesis.  Heel-to-knee  test  well 
performed  on  l)oth  sides.  Straightening  the  lower  extremities  after  the  knees  have 
been  flexed  on  the  body  appears  to  be  well  performed." 

Eye  examination  by  Dr.  L.  Webster  Fox  showed  choroid  involved,  maculae  and 
retinae  edematous.  Vision,  only  shadow  and  light.  Field  of  vision,  nil.  Color 
perception,  nil. 

X-ray  examination  on  November  27,  1914.  Diagnosis:  Pituitary  tumor. 
Partial  absorption  of  bone  salts  in  the  left  cerebellar  region.  The  sella  turcica  is 
enlarged  and  the  posterior  clinoid  process  is  elongated  and  jiartially  absorbed. 
There  is  an  area  of  absorption  of  lime  salts  about  %  of  an  inch  in  diameter  bor- 
dering on  the  left  side  of  the  foramen  magnum. 

The  Wassei'mann  test  of  the  blood  was  strongly  positive. 

Examination  of  the  vestibular  apparatus  was  made  on  November  27,  1911, 
and  tindings  recorded  on  the  accompanying  chart  (XXX).  The  exaggerated 
nystagmus  after  turning  Ls  indicative  of  an  irritation  of  the  Ijrain-stem,  as  from 
pressure.  Turning  and  douching  both  produced  a  good  nystagmus,  from  the 
horizontal  canals  and  the  vertical  canals  of  both  ears;  this  would  indicate  that  the 
medulla  oblongata  and  pons  themselves  were  intact.  There  is  a  striking  absence  of 
past-j^ointing  of  the  left  ann  to  the  left,  both  after  turning  to  the  left  and  after 
douching  the  left  ear  with  cold  water — both  of  which  should  normally  produce  a 
past-pointing  of  the  left  arm  to  the  left.  The  following  report  was  made:  "The 
ear  tests  suggest  a  cerebellar  lesion,  in  the  left  lateral  hemisphere,  in  the  region 
governing  the  outward  pointing  centre  of  the  left  upper  extremity.  The  following 
appear  normal :  (1)  Both  labyrinths.  (2)  Both  Till  Xen^es,  (3)  Medulla  oblongata, 
(4)   Pons." 

Operation  :  Bilateral  cerebellar  exi^osure,  dura  found  to  be  tense  and  on  opening 
the  dura  on  a  Avide  exposure  no  removable  tumor  mass  was  found. 

Autopsy. — The  following  is  the  report  of  Dr.  T.  H.  Weisenburg:  "There  is  a 
softening  of  the  left  cerebellar  hemisphere,  taking  in  chiefly  the  anterior  internal 
portion  of  the  quadrangular  lobe,  extending  as  a  gelatinous  mass  in  the  left  cere- 
belloi)ontile  angle  and  contiguous  with  the  medulla  oblongata.  The  softening 
extends  into  the  left  side  of  the  vermis  and  also  involves  the  right  dentate  nucleus. 
The  aqueduct  of  Sylvius  is  almost  obliterated  by  the  tumor  mass.  The  right  cere- 
bellar hemisphere  and  the  right  side  of  the  vermis  ai'e  normal.  The  outer  portion 
of  the  left  quadrangular  lobe  is  also  normal." 

Ca.se  17. — Agatha  I.,  age  two  and  one-half. 


PATHOLOGIC  CASES  ANALYZED  369 

This  case  illustrates  the  value  of  a  thorough  testing  of  the  vestibular  apparatus 
in  cases  of  intracranial  complication  in  the  course  of  middle-ear  suppuration. 
Three  weeks  prior  to  this  ear  examination  a  simple  mastoid  operation  had  been 
done  on  the  right  ear.  Three  days  j^rior  to  the  examination,  during  what  appeared 
to  be  an  uninterrupted  convalescence,  the  patient  began  to  be  semi-stuporous  and 
the  pulse  became  slower  and  slower.  There  were  no  chills  and  the  temperature 
remained  about  normal.  It  Avas  evident  that  there  was  some  intracranial  complica- 
tion. The  differential  diagnosis  lay  between  lateral  sinus  or  jugular  thrombosis, 
meningitis,  cerebellar  abscess,  or  tempero-sphenoidal  abscess. 

The  ear  examination  on  January  7,  1916,  showed  the  following : 

(1)  Douching  the  right  ear  on  two  different  occasions  failed  to  produce  any 
response  w-hatsoever.  The  ear  was  douched  both  with  the  head  in  the  upright 
position,  stimulating  the  vertical  canals,  as  well  as  with  the  head  60°  backw-ard, 
stimulating  the  horizontal  canal.     Neither  test  elicited  any  nystagmus. 

(2)  Douching  the  left  ear  with  cold  water  produced  a  conjugate  deviation  to 
the  left,  after  one  minute  and  thirty  seconds.  On  two  occasions  the  left  ear  was 
douched  Avith  hot  water,  producing  a  conjugate  deviation  of  both  eyes  to  the  right. 

There  was  an  occasional  spontaneous  vertical  nystagmus  upward. 

The  clinical  picture  of  itself  was  sufticient  to  exclude  lateral  sinus  or  jugular 
thrombosis  as  well  as  meningitis.  The  presence  of  a  slow  pulse  was  most  suggestive 
of  a  purulent  collection  Avithin  the  cranium.  There  was  nothing,  hoAvever,  AA^iich 
would  indicate  whether  the  pus  Avas  in  the  cerebellum  or  in  the  tempero-sphenoidal 
lobe.  The  responses  to  the  ear  stimulation,  hoAvever,  Avere  very  suggestive.  A  tem- 
poro-sphenoidal  abscess  could  hardly  account  for  a  total  aljsence  of  reactions  from 
the  right  ear  as  Avell  as  the  occasional  spontaneous  vertical  nystagmus.  This  total 
absence  of  responses  from  the  right  ear  clearly  indicated  a  destruction  of  either  the 
labyrinth,  the  VIII  Nerve,  or  a  collection  of  pus  in  the  right  cerebello-pontile  angle 
involving  the  VIII  Nei-ve.  Since  the  clinical  picture  pointed  to  an  intracranial 
abscess  the  question  of  a  purulent  labyrinthitis  could  be  disregarded  and  it  seemed 
most  probable  that  the  case  Avas  one  Avith  an  abscess  in  the  cerebellum  in  its  anterior 
portion  pressing  into  the  angle  or  a  collection  of  pus  AAathin  the  angle  itself.  At 
any  rate  the  surgical  indications  Avere  an  exploration  of  the  posterior  and  not  the 
middle  fossa  of  the  skull.  On  the  strength  of  this  information  the  right  cerebellum 
was  explored  and  three  teaspoonfuls  of  fetid  pus  evacuated. 

Case  18. — Mr.  Harold  S.,  age  16.  This  patient  was  examined  by  us  at  a  clinic 
given  by  Dr.  G.  E.  Shambaugh  in  Chicago  June  17,  1915.  The  examination  of  the 
vestibular  apparatus  Avas  carried  out  Avithout  any  knoAvledge  of  his  preA'ious  histoiy, 
and  the  report  was  made  exclusively  on  the  basis  of  the  findings  obtained  by  turn- 
ing and  douching.  The  accompanying  chart  (XXXI)  presents  the  data  obtained 
at  this  examination.  A  glance  at  the  markedly  abnonnal  responses  shown  on  the 
A'estibular  chart  indicates  at  once  an  organic  lesion  in  some  portion  of  the  vestibular 
mechanism.  The  labyrinths  and  VIII  Nerves  can  be  excluded  because  the  hearing 
is  normal  and  turning  in  both  directions  produced  a  large  nystagmus.  The  lesion, 
therefore,  is  central.  The  most  striking  abnormalities  are  the  subnormal  vertigo 
and  the  peculiar  past-pointing.  Nausea,  dizziness  and  vomiting  were  strikingly 
absent  in  spite  of  the  fact  that  the  entire  series  of  tests  Avas  carried  out  at  one  sitting 
24 


t}70  EQIILIBRII  M  AND  VERTKIO 


CHART  XXXI  A 


Xime      -  I 


^^OA^UcLof.  A«e/6  WA^tLl'f/iCj/S- 


^''"^^      a  ^^  ^- 


Referred  by 
DIAGNOSIS: 

SUMMARY: 


Complains  of 


HISTORY:  ,  ///?', 

Dizziness     V    •Jr»^     (XuJ-AJ^Jca^^^ 


Staggering 

Deafness 

Tinnitus 


NOSE:  ^ 

THROAT:^ 

A.  D.  ^^^y^Zjt^  0,.^,^^-iJU^   ,  X^<!^^T 

EARS:  '  /  0-^    / 

A.  S.  %riy(jtiJ  'V-»v-a--&^  ,    J/.uL».<^  . 

Fistula    v/^*^   ZtUXi^iC 

A  I  A  1  Ac  Be  n  Fol.  j 

=1  i  Ac  Be  n  ' 


PATHOLOGIC  CASES  ANALYZED 


371 


CHART  XXXI  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT  ^/<»*«^ 
Looking  to  LEFT  -^.«'vi^ 
Looking  UP  yr^rvji^ 
Looking  DOWN  -^-^ 


SPONTANEOUS 


Shoulder  from  above 


Nystagmus   ^^r-* 

Vertigo    w^.<rv^J^' 

Past-pointing   ■Jhrvjt. 

Falling    ^^v^ 

Romberg      y/}-»4-  -  jdiJCuJL 
Turning  head  to  right  ^^4-'  XJi^ZcJi 
Turning  head  to  left     ^h^  TCUXLjL 
Attempt  to  overthrow  Jh»^  XitJfLJL 


POINTING 


RIGHT 


LEFT 


To  RIGHT    > 

Amp.  <\.<vL«t^ 
Duration  ^in^ec. 


TURNING 


To  RIGHT 
Shoulder  from  above 


JiM^jKimJ^ 


To  LEFT    <- 


Amp.  K.'^J^f^ 
Duration  ^toSec. 


Nystagmus  0^*^a*^i^'XiJ- 

Vertigo  (j)]»>4-H-»'u»«aX 

Past-pointing  J-,maJ)cm*J  -<-»»<<  A*^u*<*JCtJL 


To  LEFT 
Shoulder  from  above 


j"to^^"to/r^^ 


^no^y<- 


uuration  ^toSec.  ^ 

4fiA^  >^.u.JdJlZ.cl^    /e..c:,u52Jystagmus      h^^^^iA^^^^ 
7^    "eLl.  AjlI^  Vertigo    0  .Jn^.^t.^^^''-*^ 

Past-pointing   J *juukowJut^ 


^"to4j^ 


Douche  RIGHT    ^O  tS  l^&f 
Amp.  ^t»»<^ 
After  i_  min.   V  sec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


^&^^*^ 


Nystagmus 


Cy>t>«r-tA^tf^t^ 


Vertigo   ^yi-^t^u:- 
Past-pointing  ^Xv.^..^  aJL%amC 
Falling  -^4^-c*U 
Head  Back    .yf^    ;^iiS^it 
Amp. 


Douche  LMT_'«i^ 

Amp.  '^y'-a^i'^ 

After         min.^Jf  sec. 


Head  Back    Jt-Ur  tUXLiL 
Amp. 


Douche  LEFT 
Shoulder  from  above 

Nystagmus  ■/tiyuf'^AXZeL 
Vertigo  ^M.^,^,.^  ,o-i<.t.,^ 
Past-pointing  ^A,..,**.^  A>M.t*jJ^ 
Falling    -j/l  Ujt,^ 


to 


>3  *  to  T^o^i^ 


X-toCif4.  /^toTc^^.' 


372  EQUILIBRIUM  AND  VERTIGO 

and  in  rapid  succession.  This  absence  of  the  normal  vertiyo  and  past-pointing  nat- 
urally at  once  suggests  a  cerebellar  lesion.  The  medulla  oblongata  would  ajjpear  to  be 
uninvolved,  because  stimulation  of  both  horizontal  semicircular  canals,  by  turning 
both  to  the  right  and  to  the  left,  produced  a  large  nystagmus;  the  prolonged  dui'a- 
tion  and  large  amplitude  of  this  nystagmus,  howevei',  would  suggest  irritation  by 
pressure.  Stimulation  of  the  right  vertical  semicircular  canals  produced  the  re- 
markable phenomenon  of  an  inverse  nj^stagmus;  stimulation  of  the  left  vertical 
semicircular  canals  produced  a  perverted  nystagmus.  These  would  suggest  an  in- 
volvement of  the  brain-stem  by  infiltration  or  pressure  from  without.  The  follow- 
ing report  was  made :  "The  ear  examination  suggests  a  lesion  of  both  sides  of  the 
cerebellum,  chiefly  the  right,  with  pressure  against  the  brain-stem." 

Following  this  statement  Dr.  Peter  Bassoe  then  gave  the  full  histoiy  of  the 
case  as  follows:  "Headache  began  to  appear  in  November.  1914,  but  not  very 
severe  until  two  weeks  ago.  Morning  vomiting  began  six  weeks  ago,  and  tendency 
to  staggering  has  been  noticed  since  January,  with  tendency  to  fall  backward  and 
to  the  right.  For  three  weeks  blurring  when  reading  and  some  degree  of  lateral 
diplopia.  Vertigo  is  sometimes  complained  of.  The  headache  was  most  severe  in 
the  forehead  and  vertex.  He  attended  school  until  March  29."  Dr.  E.  Y.  L.  Brown 
discovered  bilateral  papillitis  on  April  1st,  whereas  only  a  few  weeks  before  another 
ophthalmologist  had  found  the  eye  grounds  normal. 

Examination. — Pupils  react  nonnally;  the  left  slightly  wider  than  the  right; 
lateral  nystagmus  on  looking  to  either  side,  more  so  when  looking-  to  the  right. 
Slight  lateral  diplopia;  fields  roughly  normal;  bilateral  choked  disc.  The  patient 
can  read  fine  print  with  either  eye.  Sense  of  smell  normal;  taste  apparently  a  little 
sluggish.  Watch  heard  at  three  feet  left  ear;  one  foot  right  ear.  Tongue  protruded 
slightly  to  the  left.  In  smiling,  however,  the  mouth  is  drawn  more  to  the  left. 
The  forehead  wrinkles  equally;  shutting  of  eyes  apparently  stronger  on  right  side. 
Muscles  of  mastication  of  normal  strength.  Right  corneal  reflex  weaker  than  left; 
sensation  everj'where  normal.  Moderate  ataxia  of  right  hand,  very  little  of  left 
hand.  Slight  adiadokokinesis  of  right  forearm.  AYrist  jerk  not  obtained;  elbow 
jerks  weak,  especially  left;  abdominal  reflexes  .weak;  cremasteic  present,  weak; 
knee  and  ankle  jerks  not  obtained ;  plantar  reflex  normal  on  both  sides. 

Diagnosis. — Tumor  of  posterior  fossa  on  right  side,  probably  in  cerebellum  or 
cerebello-pontile  angle.     Operation  advised. 

The  ojDeration  was  performed  in  two  stages  by  Dr.  Dean  D.  Lewis.  The  two 
operations  were  eight  or  ten  days  apart.  At  the  second  one,  performed  on  April 
29th,  a  cyst  Avas  discovered  deep  in  the  right  lateral  lobe  of  the  cerebellum  and  about 
25  e.e.  of  straw-colored  fluid  evacuated.  "When  the  dura  first  was  opened  and  the 
cerebellum  palpated  no  difference  in  tension  between  the  two  halves  could  be  made 
out,  nor  did  inspection  offer  any  clue  to  the  site  of  the  lesion.  The  cyst  Avas  dis- 
covered by  the  introduction  of  an  aspirating  needle. 

The  patient  impioved  very  rapidly. 

It  is  of  interest  to  note  that  the  ear-examination  was  made 
after  the  patient  had  recovered  from  this  operation  ;  Doctor  Bassoe 


PATHOLOGIC  CASES  ANALYZED  373 

and  Dr.  Dean  Lewis  knew  the  location  of  the  lesion  and  it  was 
therefore  a  good  ojoportunity  to  test  the  accuracy  of  an  examina- 
tion of  the  vestibular  apparatus. 


Case  19. — Mr.  Leo  S.,  age  2U.  Patient  admitted  to  the  Hospital  of  the  Uni- 
versity of  Pennsylvania  on  May  10,  1916,  comiDlaining  of  vertigo,  loss  of  memory 
and  headache.  Seven  months  prior  to  admission  it  was  noted  by  the  patient  and  his 
friends  that  his  violin  playing  had  ijercei^tibly  deteriorated.  It  was  noted  at  the 
same  time  that  his  general  mentality  was  failing.  Five  months  ago  he  began  to  com- 
plain of  dizziness;  objects  appeared  to  be  moving-  from  right  to  left.  For  the  last 
two  months  he  has  had  a  staggering  gait.  Headache  api^eared  two  weeks  ago  and 
is  persistent;  it  is  mostly  ot'cii)ital,  but  fi-ecjuently  also  frontal.  For  the  last  four 
months  his  vision  has  been  failing.  Gives  no  history  of  having  had  any  con- 
vulsions, i^aralysis  or  objective  sensory  disturbances. 

The  previous  medical  and  family  history  are  negative. 

Phtjsiccd  exaunnation. — Frequent  ti'emor  of  neck  muscles  with  nodding  move- 
ments of  the  head.  Action  of  facial,  pharyngeal  and  tongue  muscles  unimpaired. 
Biceps  reflexes  jjrompt  and  equal.  Knee  jerks  equal,  but  somewhat  more  sluggish 
than  the  other  reflexes.  Achilles  prompt  and  equal.  Plantar  stimulation  of  either 
foot  induces  jolantar  flexion.  No  ankle  clonus.  Tactile  and  pain  sensation  are 
normal  throughout,  (irip  strong  and  equal.  Patient  unsteady.  Swaying  is  in- 
creased when  eyes  are  shut.  Gait  tends  to  ataxia  and  inco-ordination.  Movements 
of  hands  are  clumsy.  Adiadokokinesis  in  both  hands.  Finger-to-nose  test  and 
heel-to-knee  test  are  done  with  moderate  accuracy.  Sense  of  position  and  move- 
ment as  well  as  steriognostic  sense  are  normal.  In  bending  backward  does  not 
flex  knee;  no  cerebellar  catatonia.     There  is  no  asynergy  in  flexion  of  lower  limbs. 

Eye  Examination. — Vision  right  eye,  6/12ths;  left,  6/16ths.  There  is  noted  a 
definite  striation  of  the  upper  margins  of  both  nerves.  Fields  normal.  There  is  a 
paresis  of  the  internal  and  external  rectus  of  the  left  eye. 

X-ray  examination  by  Dr.  Pancoast  negative. 

Lumbar  puncture  shows  the  si^inal  fluid  under  a  pressure  of  S  m.m.;  it  is  clear; 
contains  very  few  cells. 

Wassermann  is  negative.  Globulins  slightly  positive. 

The  results  of  the  examination  of  the  vestibular  appai'atus  are  recorded  on  the 
accompanying  chart  (XXXII).  It  will  be  noted  that  tlie  patient  is  unable  to  look 
to  the  right,  with  the  left  eye.  Ear  stimulation,  however,  does  cause  a  definite 
contraction  of  the  internal  rectus  of  the  left  eye;  this  movement  is  not  complete  and 
does  not  draw  the  eye  completely  inward,  but  it  shows  definitely  that  the  left  III 
nucleus  is  not  completely  paralyzed  (unless  certain  fibres  come  from  the  right  III 
nucleus  to  the  left  internal  muscle). 

The  marked  vertical  nystagmus  upward  and  also  vertical  nystagmus  down- 
ward indicate  a  lesion  of  the  brain-stem  either  by  infiltration  or  pressure.  After 
ear  stimulation  from  every  canal  except  the  left  horizontal,  there  is  a  perverted 
nystagmus;  on  turning  both  to  the  right  and  to  the  left  there  is  produced  not  a  pure 


374  EQUILIBRIUM  AND  VERTK.O 


CHART  XXXIl  A 


Name 

Address 


J^^  ^  Age  ^O  Date  ^  /''-  7^^ 

Referred  by     Z^^.-^'i'-t**^    c^f^-*-^ZZ^  - 


7 


DIAGNOSIS: 


SUMMARY. 


Complains  of    Q-^^-'-o**.,  .^Z^t^^^a,  jCc-^^-^e-^^^/- 

HISTORY:  /       •       ,  -r"        ;  ^ 

Dizziness     Qty^/^^t^C-      ^t^i^^i-i^-tT-     It-J-Orun^t^q     iyLjtA,liiC*,ni^     /rr     <^^***<^i-»tCc- 

Staggering    i^ot,  '^ 

Deafness     J).   ->«..v.^^^     .<<^**.aZ<,,^  ,    f^-Lt-    tA^  -rr-x.^t^   A^^ia.^^   ^tA^. 

Tinnitus    ^^.  ^  ' 


NOSE:        "tW    t^o^^-i-vi^E^ 
THROAT:      ^^  cv^i*.i«.<-<^ 


A 


.  D.    dJo-t-'^  -<«'«^    ^^^ 


EARS:  ^;^^ — -r-  /  /   -     ■/         J     /....w^^*.   ^-o-'^^-^  .««»v.«t. 


Fistula 


Hearing  Testa  ,4 .  ^  ..  ■    L 

\\l  Al/o  Ac     >      Be   <       n  Pol.  c«  pt^^t^Galt    •  ^ 

=  1  U  Ac     >      Be    <       n  I  \j)^        ''         '  •  *» 


PATHOLOGIC  CASES  ANALYZED 


575 


CHART  XXXII  B 


NYSTAGMUS 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


POINTING 


RIGHT 

Shoulder  from  above  ^^lL*/i-«^ 

Nystagmus  JU^fyi^^y^  *^  -o-^  y^^A4.^Zlnt^ 
Vertigo  -^*»u^ 
Past-pointing   -r>vi<- 
Falling    -AjtmA^ 

Romberg    ^ff^u\ALjL   fL-,^,^   -^  ^UZ-  <<i.4-t*^«*</.. 
-  Turning  head  to  right  /-jU/^  :£»  ^^JLC. 

■  ^  f.t^  -cyu  >i^"^*^Tuming  head  to  left  ••  ••  •■  •  • 

{^iL4^«A«.  f1  J^ij4  IUJmm.»JL  — ^       Attempt  to  overthrow  PaX^^^^  ^,u-»6^c  At/**.^-^-*-  "'^^ 


Looking  to  RIGHT   « — 
Lookbg  to  LEFr»i'y^ 
Looking  UP     i 
Looking  DOWN     \j 


U 


LEFT 


yi<»^T-. 


To  RIGHT  <iA~<   --^ 
Amp.  /^"^ 
Duration  i^Sec. 


TURNING 

A.^  .^^A^l^  To  RIGHT 

Shoulder  from  above 

Nystagmus  fc^^^^x**^^ 
Vertigo  .-fjCjb^ 
Past-pointing  .4^i*^CM4. 


To  LEFT  'oU^  ^--  ■•■mJ.  *i^'pAtu      Xo  LEFT 

Amp.  \«^  *■  Shoulder  from  above 

Duration  V«  Sec. 
.,1^.  V-  -*-       Nystagmus  <5v.M«o«;Ci^ 

^^^^-^  ^    7^*7^      Vertigo    cfA^ii/ 
^.tcv^kZZX.   ^  '^^^*/^  Past-pointing  ^^c<~^ 


^^^litl^ 


f-r.oC^ 


^^JZJi^Jt. 


^^SZJ^j^ 


Douche  RIGHT    ^■ 
Amp. 
After   i^  min. 


Head  Back    ^/•w 
Amp. 

Douche  LEFT     <: 

Amp.  ^te-u) 

After  £i  min.  J  a  sec. 


Head  Back    < — 
Amp.     %»^*-«t 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  •yr^\>x^ 
Vertigo   ./fvu^u-o/^ 
Past-pointing  ,/fvw*- 
Falling   JI-omj^ 

V\AjCZat 

Douche  LEFT 
Shoulder  from  above 


Nystagmus  y-***^  •< 
Vertigo  ^jf\M-»X- 


A*.»*^«yit^ 


Past-pointing 


ointing  i„,uiC.ijJU>^  -<»,A.£«*X 
Falling  kJ-.x^cm*^  ' 


:t'to^ 


376  EQUILIBRIUM  AND  VERTIGO 

horizontal  nystagniiis,  but  a  mixed  horizontal  and  ol)li(|iie,  as  'well  as  an  oeeasional 
upward.     This  further  suggests  brain-stem  involvement. 

After  turning  there  is  a  noticeably  long  duration  of  the  nystagmus.  This 
usually  indicates  a  neuraxial  disturbance  and  of  itself  points  to  pressure  rather 
than  destruction  of  the  fibres. 

After  turning,  the  nystagmus  is  large  and  very  slow;  this  suggests  an  impair- 
ment of  the  cerebral  fibres  which  fail  to  bring  about  a  quick  return  movement  of 
the  eye. 

Stimulation  of  the  right  ^■ertical  canals  fails  to  produce  any  nystagmus,  indi- 
cating a  lesion  in  the  upper  part  of  the  pons.  Inasmuch,  however,  as  the  vertical 
canals  of  the  right  did  i)rodnee  vertigo,  the  lesion  indicated  would  be  in  the  region 
of  the  jDOsterior  longitudinal  bundles  rather  than  of  the  right  middle  cerebellar 
peduncles.  Vertigo  was  also  produced  by  ])oth  ]u)ri7,ontal  canals;  this  suggests 
uninvolved  inferior  cerebellar  peduncles. 

All  of  the  semicircular  canals  produced  vertigo,  although  it  was  impaired  from 
some  of  them.  This  suggests  that  the  decussation  of  the  superior  cerebejlar  pe- 
duncles in  the  neuraxis  at  the  base  of  the  cerebral  crura  is  not  involved.  This 
is  rather  surprising,  becaiise  the  impairment  of  the  Cjuick  component  of  nystagmus 
suggests  a  lesion  very  near  this  point. 

The  fibres  from  the  left  vertical  canals  in  the  upper  portion  of  the  pons  ap- 
pear definitely  encroached  upon,  in  the  region  of  the  posterior  longitudinal  bundles, 
but  not  completely  blocked  as  are  the  right  vertical  canals  fibres. 

The  horizontal  canals  of  both  sides  cause  more  vertigo  than  the  vertical  canals; 
this  bears  out  other  data  suggesting  that  the  lesion  is  in  the  upper  part  of  the 
cerebellum  and  brain-stem  rather  than  in  the  lower  part. 

Pointing.  Spontaneous  pointing  shows  a  slight  ataxia  of  both  arms.  The 
right  arm  occasionally  points  towards  the  left,  this  ■per  se,  Avould  suggest  a  lesion 
of  the  outward  pointing  centre  of  the  right  lateral  cerebellar  hemisphere.  This 
is  further  borne  out  by  the  inaltility  to  cause  the  right  arm  to  point  outward  by 
ear-stimulation.  There  is  a  definite  absence  of  past-pointing  outward  of  the  right 
arm  after  turning  to  the  right,  after  douching  the  right  ear  with  cold  water,  or 
after  douching  the  left  ear  with  hot  Avater;  all  of  these  tests  should  cause  the  right, 
arm  to  point  outward.  It  is  true  that  after  turning,  the  left  arm  also  fails  to  point 
to  the  right,  but  cold  water  to  the  right  horizontal  canal  produces  a  definite  past- 
pointing  of  4  inches  of  the  left  arm  to  the  right,  and  douching  the  left  horizontal 
canal  with  hot  water  also  causes  a  correct  past-pointing  of  the  left  arm  to  the  right. 
All  this  points  to  a  lesion  of  the  outward  pointing  centre  of  the  right  lateral  cere- 
bellar hemisphere;  this  centre  is  supposed  to  be  located  on  the  upper  surface  of  the 
cerebellum  toward  the  median  line  in  the  c|uadrangular  lobe.  (Bai'any's  idea,  how- 
ever, is  that  this  centre  is  in  the  semilunar  lobe,  both  superior  and  inferior,  in  the 
region  of  the  large  fissure.) 

Inasmuch  as  the  patient  experiences  vertigo  from  ear-stimulation,  and  yet 
shows  marked  absence  of  past-]:)ointing  of  both  arms,  in  both  directions,  more  par- 
ticularly the  right  arm,  it  is  suggested  that  the  motor  fibres  from  the  cerebral 
^'ortex  are  interrupted,  either  in  the  brain-stem   or  in  the  cerebellum  itself. 


PATHOLOGIC  CASES  ANALYZED  377 

The  pelvic  girdle  reactions  are  so  markedly  impaired  that  a  lesion  of  the  vermis 
is  indicated. 

There  is  evidence,  therefore,  of  involvement  of  the  right  lateral  cerebellar 
hemisphere,  the  vermis,  the  left  lateral  hemisphere  of  the  cerebellum,  the  upper 
posterior  portion  of  the  pons,  and  the  posterior  portion  of  the  junction  of  the  cere- 
bral crura.  It  is  evident,  therefore,  that  some  of  these  phenomena  are  due  to  pres- 
sure. Howevei",  as  there  is  such  marked  involvement  of  the  brain-stem  itself,  it 
would  appear  that  the  lesion,  if  a  tumor,  is  inoperable.  The  most  flagrant  absence  of 
reaction  is  in  the  outward  pointing-  of  the  right  arm.  The  best  explanation  would 
be  an  infiltrating  glioma  involving  the  outward  pointing  centre  of  the  right  lateral 
cerebellar  hemisphere,  extending  over  to  the  vermis  and  entering  the  pons  at  its 
upper  half,  and  extending  into  the  base  of  the  junction  of  the  cerebral  crura. 

The  patient  was  operated  upon  on  June  21.  191(i,  by  Dr.  C.  H.  Frazier.  Report 
of  operation :  "A  suboccipital  craniectomy.  Wide  exposure  of  both  cerebellar  hemis- 
pheres. Superior,  inferior  and  lateral  aspects  of  the  hemispheres  seem  to  be  entirely 
free  from  suspicion  of  tumor.  In  the  median  axis,  however,  coming  up  from  the  two 
hemispheres,  was  seen  what  appeared  to  be  a  gliomatous  growth  of  infiltrating  char- 
acter, soft  and  gray  in  appearance,  a  portion  of  which  was  removed  for  examina- 
tion. Possibility  of  involvement  of  both  hemispheres  and  the  pons  as  indicated  in 
the  ear  report  seems  quite  proljable." 

Case  20. — Richard  Z.,  age  13.  Patient  was  admitted  to  the  Jefferson  Hos- 
pital on  April  10,  1917,  complaining  of  inability  to  walk,  blindness  and  general 
weakness. 

About  one  year  ago,  while  .sleighing,  patient  was  thrown  to  the  ground;  he 
was  dazed  by  the  fall,  but  soon  after  being  carried  into  the  school  room  he  became 
normal  again.  In  April,  1916.  that  is,  about  a  montli  later,  he  began  to  have  severe 
headaches.  A  month  later  he  began  to  vomit.  This  vomiting  recurred  with  greater 
or  lesser  frequency  for  several  months.  Eight  months  ago  the  patient  had  a 
"fainting  spell"  followed  by  convulsive  movements  of  the  hands  and  legs;  the 
head  was  drawn  back  and  there  was  a  rolling  of  the  eyes.  Similar  convulsions 
occurred  rather  frequently  until  about  two  weeks  before  admission  to  the  hospital. 
Patient  has  been  unable  to  walk  and  was  confined  to  bed  during  the  five  months 
immediately  preceeding  his  admission  to  the  hospital.  Two  months  ago  patient 
became  dull  and  the  speech  became  explosive. 

Family  and  previous  medical  history  are  negative. 

Physical  Examination. — Patient  emaciated  and  unable  to  walk.  Knee  jerks 
absent.  Double  Babinski.  No  loss  of  sensation.  General  weakness  but  no  paralysis 
of  extremities.  Finger-to-nose  test  shows  a  loss  of  co-ordination.  There  is  adia- 
dokokinesis  of  the  right  side. 

Ei/e  Examination. — No  light  perception  in  either  eye.  Pupils  do  not  react 
to  light,  but  do  react  to  convergence  and  accommodation.  Ocular  movements  unim- 
paired. There  is  a  choking  of  the  disc  in  both  eyes — 2  diopters  in  the  right  and  5 
diopters  in  the  left.     There  is  also  evidence  of  a  secondary  atrophy  in  both  eyes. 

Wassermann  negative. 

Findings  of  the  examination  of  the  vestibular  apparatus  are  recorded  on  the 
accompanying  chart   (XXXIII). 


378  EQUILIBRIUM  AND  VERTIGO 

CHART  XXXIII  A 


\{tf^^  .  '^^'^  Date  ^/^  //•,   /;/;: 


Name 
idd 

Referred 


DIAGNOSIS: 


SUMMARY: 


Complains  of  ^A^coyUt^^i^ly    ti    t,;-ajt/L      'kJt...vL..^LtL.A£.^  ^    S-.o-M-e^"^-*-*/^ 


HISTORY: 

Dizziness     Jet, 
Staggering     ^^oa^ 
Deafness     J^^n,J^ 
Tinnitus      f^j^ 


NOSE:       »/r>/  .x^<UK.--c<.-fc<<^ 
THROAT:       ^-t^  jt^<x,u,i^^.^'^-«JL 

EARS: 

A.  S. 


Fistula     J^^  tUOZJL 


Hearing  Tests 

=i     'i     t    I    :    "'-\     -I      -^-i 


^ 


Ot^vu^^i   >uva*xx^,    UZ^ 


PATHOLOGIC  CASES  ANALYZED 


379 


CHART  XXXI 1 1  B 


NYSTAGMUS 
Looking  to  RIGHT  -^I''^^ 
Looking  to  LEFT  Ji/r^^*- 
Looking  UP  »/' ^vi/t 
Looking  DOWN  c4'e^iy 


TESTS  OF  THE  VESTIBUIAR  APPARATUS 
SPONTANEOUS 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus    ^-rrn^ 

Vertigo    y)-nui^ 

Past-pointing    A/rvjiJlicJUo    )<-»-m^ 

Falling  g 

Tu^ng\ead  to  right   1     ^^-*^^     ^    "^^^^    -/- 
Turning  head  to  left       f 
Attempt  to  overthrow  / 


Jll/•^t..r^'LelAy^A~0^^^^*^^~ 


LEFT 


TURNING 


To  RIGHT 

Shoulder  from  above 


To  RIGHT  5- 

Amp.  K'-'y*^ 
Duration  J  I' Sec 

_      Nystagmus     A<r\^t^^U^ 
€,c^u^Ul   ^«/**<-iiX»'^  !>         Vertigo  '^xAI ,,,j,.^.UZjLj     ,<u*A«-en*.^«^ 
'stx  /^tx  itjJ-  o^  /"^  '"/^    Past-pointmg  J-^.oJia.,^-,,.^ 

To  LEFT    < j       ToLEIT 

Amp.  <d/T«fc  Shoulder  from  above 

Duration  3oSec 


,     ^      .      J        ,       ,',      J-     Nystagmus  &^4v/i«^^ 
M  y^^i^    <^^^,^J.U.    ^      Vertigo    i.^JL-^J-L^ 
/P^^  ZiifcM.  <i<nijt^a^^    .<:^««ii -Past-pointing   Jt^aA*<^ 


P^elJ--  ji-^-J^     tWA** 


^«*^      O-l^'^^ClM.t.ilt- 


A^^"^ 


Douche  RIGHT    — >  ^^ 

Amp.  jCi^oT 

After    /    min.  J  o  sec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  Jin^'-i^i^-'^ 

Past-pointing    aZ-k^^-  'Rc^iX  -a^v«— 
Falling  S^«Xv.-»^i>*^^^ 
Head  Back     Q^^^yc^ui    ^.ttv^A^Z^--.  ^   /^-^-^ 
Amp.  ' 


Douche  LEFT  )k^£^  y^HZj^ 
Amp. 
After    /     niin.  Jo  sec. 


Head  Back    (SrW"^&21 
Amp.         ^' 


^     Douche  LEFr 

|i     Shoulder  from  above 

Nystagmus    -^  n>*-MZi^ 
Vertigo     0.ct/-»-»A-*<-»^ 
Past-pointing     J}-tA*^A^ 
Falling      Jy  jtAAAx^Jt, 


i'-'to/'./^ 


3'  \.o%jlf-. 

/"to;^ 


D.-to^^^-d-io/Xli. 


580 


K(^riLIBRn\AI  AM)  VERTIGO 


It  will  be  noted  that  we  are  oliviously  dealiiii;'  with  a  central  lesion.     The  fol- 
lowing are  the  most  striking-  resnlts  of  the  ear-examination: 

(1)    Impaired  verliiio  from  the  stiiuulntion  of  all  of  tiie  semicircular  canals. 


Fig.   118. — Cerebellar  cortex  uninvolvod.     (Ca.se  20). 


(2)  A  perverted  n^'slaynius  obtained  on  stimulation  of  the  vertical  semicircular 
canals  of  both  sides. 

(3)  A  marked  tendency  to  a  conjug-ate  deviation  from  the  stimulation  of  both 
horizontal  semicircular  canals.  This  indicates  that  the  cerebral  comj^onent  of  the 
nystagmus  to  right  and  to  left  is  imjiaircd.     The  impairment  of  vertigo  from  the 


PATHOLOGIC  CASES  ANALYZED 


381 


stimulation  of  both  eai's  would  suggest  a  lesion  at  the  point  where  all  the  vertigo 
hl)res  come  together,  namely,  at  the  decussation  of  the  two  superior  cerebellar 
peduncles.  This  is  further  coiToborated  by  the  interference  of  both  cerebral  eom- 
jionents  of  nystagmus.  Patient's  inability  to  sit  up  or  stand  i;p  was  due  to  inco- 
ordination of  his  trunkal  muscles.  This  would  suggest  an  involvement  of  the 
vermis  of  the  cerebellum.  The  poor  responses  in  past-pointing  would  also  suggest 
an  involvement  of  the  cerebellum.  Both  arms,  however,  did  past-point  in  the  cor- 
i-ect  direction,  althougii  only  slightly.  This  would  indicate  that  the  cerebellar  cortex 
itself  is  practically  intact.     The  following  report  was  made:  "The  lesion  is  prob- 


FiG.    119. — CVrebcllar  cortex  intact.      (Case  20), 


ably  located  at  the  junction  of  the  anterior  superior  portion  of  the  cerebellum 
with  the  brain-stem.  The  lesion  ajipears  to  spring  from  the  brain-stem  itself  at 
the  region  of  the  i^osterior  corpora  quadrigemina,  or  from  the  posterior  aspect  of 
the  junction  of  the  cerebral  crura  just  above  the  region  of  the  III  nuclei  and  is 
centrally  located. 

'*  The  cerebellar  phenomena  would  appear  to  be  due  to  an  involvement  of  the 
motor  fibres  on  the  way  to  the  cerebellum,  rather  than  a  lesion  of  the  cerebellar 
cortex  it.self." 

Autopsij  by  Doctor  Funk. — I'pon  removing  the  skull  cap  a  considerable  amount 
of  clear,  colorless  fluid  escapes,  ai)i)arently  coming  from  beneath  the  membranes  in 


382 


EQUILIBRIUM  AND  \  ERTIGO 


region  of  cerebelluin.  Transverse  sections  throug-li  both  cerebral  hemispheres  reveal 
nothing  abnormal.  There  is,  however,  an  opening'  in  the  cerebellnm  which  leads 
into  the  brain  snbstance  for  a  distance  of  6.5  cm.  The  walls  of  the  collapsed  open- 
ing are  smooth,  bnt  the  dura  bordering  it  has  rough  and  ragged  edges.  Upon 
slight  pressui-e  a  small   amount  of  fluid,  similar  to  that  which   escapes  when  the 


Fig.   120. — Cerebellar  cortex  intact.     Cyst  involving  vermis.    (Case  20). 


skull  cap  was  removed,  can  be  seen  oozing  from  the  opening  (Figs.  118,  119,  120). 
Case  21. — Miss  C,  age  23.  The  patient  was  apparently  in  perfect  health  one 
month  before  her  death.  Her  illness  began  with  intense  and  frequently  recurring 
pain  in  the  head,  attacks  of  nausea  and  at  times  projectile  vomiting.  Dr.  Charles 
K.  Mills  made  the  following  notes  of  his  examination  :  "Complete  atonia  or  flaocid 


PATHOLOGIC  CASES  ANALYZED 


383 


paralysis  of  the  left  upper  and  lower  exti-emities ;  some  paresis  of  the  face  of 
cerebral  type;  Jacksonian  epilepsy,  beginning  in  the  left  side  of  the  face;  astei'iog- 
nosis;  some  impairment  of  cutaneous  and  muscular  sensibility;  somewhat  increased 
deep   and  superficial   reflexes;   negative   Babinski;   considerable   mental  hebetude." 


RIGHT 


LEFT 


TEMPORAL 
LOBE 


Fig.    121. — Abscess,  sub-cortical,  right  parietal  region. 


Dr.  Holloway   reported  marked  papilloedema.     Diagnosis   by   Dr.   Mills :   ''Tumor 
involving  both  the  parietal  and  frontal  regions  on  the  right  side." 

On  the  accompanying  chart  (XXXIV)  we  note  the  details  of  the  ear  examina- 
tion. There  is  no  spontaneous  nystagmus  and  no  spontaneous  past-pointing  of  th© 
right  arm ;  the  pointing  tests  of  the  left  arm  can  not  be  undertaken  because  of  the 


38i  EQUILIBRIUM  AND  VI:RTIG0 


CHART  XXXn    A 


.Vame   ■J{'(^2A^     C?-  Age   -5  3  Date  t^^'-t/  ^ .  /  ^  /  fo 

Referred  by  Q/T    %  ^-^l^     ^  ^Ju/^ 


DIAGNOSIS: 


SOIMARY: 


Complains  of 


HISTORY: 

Dizziness  ^'<^^y 

Staggering  2/t^ 

Deafness  "^a 

Tinnitus  ~yho  ■ 


NOSE: 


THROAT: 


EARS:  ./        7         /  / 

A.  S.        &,.a^^j.. 


Fistula 


Hearing  Tests  ^  ^XlV 

A|^  A|'^  Ac      >     Be    >      n  Pol.  |  c' I  ^-«<     Gait  I.  / 

~Ij5-  I/O  Ac     >     Be    >      n  1  \^U*^  I.V  -^ 


PATHOLOGIC  CASES  ANALYZED 


385 


CHART  XXXIV  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 

POINTING 

A 

RIGHT 

LEFT 

Looking  to  RIGHT      ^t-^ru^ 

1       Shoulder  from  above 

^=^<>T,4,-<1^^ 

Looking  to  LEFT    ^r,<ruA. 

1 

"^^ 

Looking  UP 

<^r/r^'^ 

Nystagmus    xJt'tnu^ 
Vertigo      4^ 

Past-pointing     yury^x^ 

Looking  DOWN    ^t/n^ 

Falling      IvU  -f^-tlZk. 

Romberg        'K«4~  'ti^iiJLjL 

Turning  head  to  right    yt^oi-  XiJLtL 

Turning  head  to  left          "            '' 

Attempt  to  overthrow       •'            " 

TURNING 

^^^""^ 

To  RIGHT 

\^^^ 

To  RIGHT 

Amp. 

^^^-^.^..^^ 

Shoulder  from  above 

to---^ 

to 

Duration 

Sec.      ^^ 

Nyststgnius                                                  ^ 
Vertigo     ^"""^^^^                               ^^^^ 
Past-pointing     ^""^^..^^^     ^^^-'^'^ 

To  LEFT 

i;i;«-i:EFT               ^"""^-^.^^ 

Amp. 

^^^ 

Shoulder  from  above 

""^^^        to 

to 

Duration 

Sec.^,.---- 

■^""^ 

^'^■--„„^^ 

^_.,^^^ 

Nystagmus 

^""--"-^ 

, 

Vertigo 

^"^■•--«^_^^ 

Past-pointing 

^"^- 

(p  "    \.oi{K^iXr  \to 


CALORIC 

Douche  RIGHT  Douche  RIGHT 

Amp.  Shoulder  from  above ' 

After  /    min.  ;J5"sec 

f^ :        r         ^,  /    n/  Nystagmus    A>  tUj^^^  a^y-K-o^*,^^...^- 

Past-pointmg    ^c^U^w./         '  ^  ' 

Falling    Ai-t,)^^ 
Head  Back    jL*^i^  ^  _^   C^L^  ^  e^...^o^.M^<^^  -?  "  '"^"^ 


Amp. 

Douche  LEFT    ^ 

Amp.  <(>A4.t^ 

After         min.  ^  *sec. 


i 


CO'i.'^LaJl^  O 


z:  Ti^lzr 


Douche  LEFT 
Shoulder  from  above 


Head  Back    <- 
Amp.  -{Lryt, 


<^'to^^ 

Nystagmus  ^^t'U'.t^  ^  atJa-liZ^  Jt^^a^  9-<AojfZ^  ^tj^jtcCLdU 

Vertigo  yh^  aJ^^,.,^      '  ^^ 

Past-pointing    Cprr\.„^'^^     ' 

Falling     i^M^t-^  ^ 


25 


386  EQUILIBRIUM  AND  VERTIGO 

paralysis.      The   turning  tests   were   not   undertaken.     The  calorie   tests   gave   the 
following  data : 

Right  Ear. —  (1)  Stimulation  of  the  right  vertical  canals  produces  a  conjugate 
rotary  rolling  of  both  eyes  to  the  right.  There  is  no  quick  recoil  of  the  eyes  to  the 
left.  The  ''quick  component"  of  the  nystagmus  is  absent,  whereas  the  "slow  com- 
ponent" is  present — instead  of  a  full  nystagmus,  therefoi'e,  there  occurs  only  this 
rolling  of  the  eyes  to  the  right. 

(2)  Vertigo  almost  entirely  absent.  This  is  made  evident  not  only  by  the  state- 
ment of  the  patient,  Avho  says  that  she  experiences  no  dizziness,  but  also  because 
there  is  absolutely  no  tendency  to  fall  toward  the  right.  There  is,  however,  a  slight 
past-pointing  of  the  right  arm  to  the  right,  which  shows  that  vertigo  is  not  entirely 
absent. 

(3)  Stimulation  of  the  right  horizontal  canal,  instead  of  producing  a  full 
rhythmic  nystagmus,  shows  exclusively  a  marked  conjugate  deviation  to  the  right. 
Both  eyes  were  drawn  to  the  right  and  remained  in  that  position ;  there  was  no 
quick  recoil  to  the  left. 

Left  Ear. —  (1)  Vertical  canals.  A  real  nystagmus  is  produced;  not  only 
are  the  eyes  drawn  to  the  left,  but  there  is  present  the  normal  quick  component  to 
the  right. 

(2)  Vertigo  slightly  impaired  but  by  no  means  absent,  as  there  is  a  past- 
pointing  of  the  right  arm  to  the  left  and  a  falling  to  the  left. 

(3)  The  left  horizontal  canal  produces  a  normal  nystagmus;  the  slow  com- 
ponent to  the  left  and  the  quick  component  to  the  right  are  both  normally  present. 

Douching  each  ear  produced  one  very  striking  phenomenon — not  the  least 
nausea  was  produced  and  yet  sudden  projectile  vomiting  occurred.  Incidentally, 
this  shows  that  there  is  probably  a  direct  pathway  from  the  ear  to  the  nuclei  of 
the  vagus  and  phrenic  nerves — the  two  nerves  concerned  in  vomiting;  this  vomiting 
was  due  to  dii'ect  stimuli  and  was  not  secondary  to  a  cerebral  sensation  of  nausea. 

The  essential  features  shown  by  the  caloric  test  on  this  patient  are : 

(1)  The  noticeable  impairment  of  vertigo  from  all  the  semicircular  canals 
shows  that  there  is  a  block  somewhere  along-  the  vestibulo-cei'ebello-cerebral  path- 
ways. 

(2)  The  eyes  are  drawn  in  the  proper  direction  by  the  ear-stimulation.  This 
would  indicate  normal  vestibulo-ocular  pathways  throughout  the  medulla  oblongata 
and  pons,  as  well  as  normal  labyrinths  and  VIII  nerves. 

(3)  The  most  striking  phenomenon  is  the  absence  of  the  quick  component  of 
nystagmus  to  the  left.  The  contrast  is  definite;  the  quick  recoil  to  the  right  is 
present  and  the  quick  recoil  to  the  left  is  absent. 

The  following  report  was  made :  "The  ear-tests  suggest  a  lesion  of  the  cere- 
brum, on  the  right  side  exclusively,  at  a  point  between  the  right  cerebral  crus  and 
the  right  cerebral  cortex.  The  following  appear  normal — both  labyrinths,  both 
VIII  Nerves,  the  medulla  oblongata,  pons  and  cerebellum." 

Autopsy,  a  few  days  after  admission,  showed  a  large  subcortical  abscess  in  the 
right  parietal  region  (Fig.  121). 


PATHOLOGIC  CASES  ANALYZED  387 

Comment 

The  following  conclusions  are  suggested  by  this  case : 

(1)  It  must  be  remembered  that  the  patient  was  able  to  look  to 
the  left  voluntarily,  and  yet  the  quick  component  of  the  nystagmus 
to  the  left  was  absent.  This  suggests  the  probability  of  two  dif- 
ferent cerebral  centres  for  eye  movement — the  one  presiding  over 
volitional  eye  movement  and  the  other  controlling  the  more  or 
less  automatic  eye  movements  such  as  are  represented  in  the  quick 
component  of  nystagmus. 

(2)  The  centre  controlling  the  quick  component  of  nystagmus 
to  the  left  is  probably  located  in  the  right  cerebral  hemisphere. 

A  point  worthy  of  mention  in  this  case  is  that  the  patient  was 
very  ill  at  the  time  of  the  examination;  the  turning  tests  were 
practically  impossible  and  at  least  unwise,  and  yet  the  douching 
tests  alone  furnished  sufficient  data  for  the  suggestions  noted 
above.  This  case  also  demonstrates  that  the  ear  tests  are  of  value 
in  cerebral  cases  as  well  as  in  the  diagnosis  of  lesions  in  the  pos- 
terior fossa. 


Case  22. — Mr.  Walter  W.,  age  35.  Patient  was  admitted  to  the  Hospital  of 
the  University  of  Pennsylvania  on  December  15,  1915,  complaining  of  pain  over  the 
right  eye  and  on  the  right  side  of  the  head,  associated  with  vertigo. 

The  trouble  began  one  year  ago;  while  asleep  in  bed  he  had  a  convulsion,  in 
which  his  legs  and  arms  were  flexed  and  he  bit  his  tongue.  Shortly  afterward  he 
developed  a  headache,  which  recurred  evei-y  two  or  three  days;  these  headaches 
were  dull  and  heavy,  lasting  several  days  at  a  time.  He  also  noticed  that  for  a 
few  minutes  one  side  of  his  body  and  face  felt  numb.  The  attacks  of  headache 
became  progressively  worse  and  after  a  period  of  two  months  became  associated 
with  vomiting.  At  this  time  he  began  to  have  pain  behind  the  eyes  and  the  feeling 
of  numbness  on  the  left  side  of  the  body  recurred.  Six  months  after  the  onset  the 
headache  changed  to  the  back  of  the  neck.  He  is  under  the  impression  that  he 
staggers  at  times  and  that  this  staggering  usually  occurs  to  the  left.  Once  in  a 
while  he  drops  things  from  his  left  hand.  His  vision  began  to  fail  three  weeks  ago. 
At  times,  especially  when  he  has  severe  headaches,  he  has  attacks  of  vertigo  in 
which  he  seems  to  be  turning  to  the  left.  His  appetite  is  good  and  there  are  no 
symptoms  referable  to  the  gastro-intestiual  tract,  lungs  or  the  cardio-renal  sys- 
tems. He  has  noticed  no  change  in  the  size  of  hLs  face,  feet  or  head.  Speech  is 
apparently  normal.  He  has  no  difficulty  in  Avriting.  He  has  had  no  convulsions 
except  the  ones  mentioned  at  the  onset  of  the  trouble. 


388  EQUILIBRIUM  AND  VERTIGO 


CHART  XXXV  A 


Name 


DIAGNOSIS: 


SUMMARY: 


Complains  of 


j/^t^U^  ^--^  ->^t/^^ 


HISTORY:  , 

Dizziness     "^"^ 
Staggering    "<4y 
Deafness    ^Vo 
Tinnitus     ^/o 


NOSE:       JrMjA^^^ 
THROAT:     -^^ 

A.  D.  wyrvu*'^^ 

EARS:  . 

A.  S.    t/r,»^x.u^<>-*^ 

*       Fistula    ^>^^^^-^^ 


Hearing  TesU  ^  ^  ,   ,  , ,  ^^^       f,  .,  ,     f        S^f-f^ 


PATHOLOGIC  CASES  ANALYZED 


389 


CHART  XXXV  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


N^'STAGMUS 
Looking  to  RIGHT  Jrovut^ 
Looking  to  LEFT  Jljrxut. 
Looking  UP    Ji'/ruA. 
Looking  DOWN  ^^-oi^^ 


POINTING 


Shoulder  from  above 


RIGHT 


/iA^^ 


Nystagmus  •/rcrux^ 
Vertigo  Jtnu. 
Past-pointing     Jr^>^x^ 
Falling 

Romberg   '^^^iuUt,  ^  /t/^ 

Turning  head  to  right    -^^  ^tCcZL^ 

AttTmTtt'fvlrthtL  ^alo^    ^  ^^  /<>M^  I'.iU^    ^^^^^^^^  ^-^i^ 


To  RIGHT  — > 
Amp.  AA/T^tr 
Duration  5^  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus  d^-^a^y^^*^^ 
Vertigo   c^a^^^o^^^^ 
Past-pointing  <x^^^^ t*«-^'^ 


To  LEFT  "^ 


Amp.  •Ca>t^i. 
Duration  j  /  Sec. 


To  LEFT 
Shoulder  from  above 


Nystagmus  S^^*'^-'^^ 
Vertigo  i§^<i-aa4A/nM^ 
Past-pointing    ^w-a^a  f/u>Zi-^ 


Douche  RIGHT    ^^ 
Amp.  5  •-•-»- 
After        min.x^j-sec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Nystagmus  Jf-'^'-'^*^ 
Vertigo  Jrt'i*'*^^ 
Past-pointing    ■^■*^^'*^ 
Falling    Vh.'vuL^^ 
Head  Back    A.^  2«;L:£^ 
Amp. 


Douche  LE^    1^ 
Amp.  ^U-<y-<L. 
After         min.-5osec. 


Douche  LEFT 
Shoulder  from  above 


Head  Back  ^<^/  ;6i:&il 
Amp. 


Nystagmus  -/r-ootti-o-c. 
Vertigo  ^,ivu.a.«.^ 
Past-pointing    y^j>'uju^a/^ 
Falling    ^,,,.4,.,.^ 


LEFT 


J^"taC^ 


J?4^ 


e^M^c*-*^ 


'to/^ 


cT-^oX^^  f"to.'^<^'^ 


(^  "tOo^ 


^■•to  .^ 


390  EQUILIBRIUM  AND  VERTIGO 

He  denies  venereal  infection.  Is  married;  his  wife  and  two  children  are  living 
and  well. 

The  following  are  the  notes  of  the  physical  examination  made  on  his  admis- 
sion to  the  hospital:  "The  patient  walks  with  a  somewhat  spastic  gait  and  appears 
to  be  weak  in  the  legs.  There  is  only  slight  swaying  when  testing  hi.s  station,  not 
sut!icient  to  call  it  a  Romberg.  There  is  marked  spasticity  in  the  left  ai'm.  The 
biceps  and  ti'iceps  jerks  in  the  left  arm  are  exaggerated.  There  is  a  suggestion  of 
ataxia  in  the  finger-to-nose  test  on  the  left  side.  Knee  jerks  are  exaggerated  on  both 
sides,  marked]}'  so  on  the  left  and  only  slightly  on  the  right.  There  is  a  distinct 
ankle  clonus  on  the  left  side  and  a  suggestion  of  a  Babinski.  On  the  right  there  is 
a  slight  non-persisting  ankle  clonus  and  the  plantar  reflexes  are  normal.  Sensation 
is  normal  throughout  the  entire  body.  No  asteriognosis  in  either  hand.  There  is  no 
paralysis  of  the  muscles  of  mastication  or  of  facial  expression.  Swallowing  is 
normal.  The  tongue  protrudes  in  midline.  Taste  is  normal.  The  sense  of  smell 
is  slightlj'  impaired. 

Examination  of  the  heart,  lungs  and  abdomen  reveals  nothing  abnormal. 

The  Wassermann  test  of  the  spinal  fluid  is  negative. 

Ej'e  examination  showed  slight  papilloedema. 

The  ear  examination  was  made  on  December  15,  1915,  and  the  data  are  re- 
corded on  the  accompanying  chart  (XXXV). 

It  is  to  be  noted  that  there  is  no  impairment  or  absence  of  any  of  the  res{)onses 
to  ear  stimulation  either  by  turning  or  douching.  This  would  suggest  an  intact 
vestibular  apparatus.  The  turning  test.?,  however.  l)rought  out  markedly  exaggerated 
nystagmus,  vertigo  and  jiast-pointing,  which  would  indicate  a  general  irritation  of 
the  vestibular  pathways  concerned  in  the  production  of  nystag-mus  and  vertigo.  The 
following  report  was  made :  "The  ear  examination  suggests  that  the  subtentorial 
region  is  affected  by  pressure  only,  from  above  or  anteriorly,  and  that  there  is  no 
lesion  within  the  medulla  oblongata  pons  or  cerebellum  themselves.  The  labyrinth 
and  VIII  Nerves  are  normal." 

The  patient  was  operated  on  by  Dr.  Charles  H.  Frazier  on  January  13.  1916, 
and  an  ino]>erable  sarcoma  of  the  right  motor  region  was  found. 

Case;  23. — Ida  B.,  age  30.  Was  admitted  to  the  Mt.  Sinai  Hospital  on  June 
22,  1916,  complaining  of  pain  and  tenderness  about  the  left  ear,  left  frontal  head- 
ache, pain  on  the  left  side  of  the  neck  when  turning  the  head  to  the  right,  and  fever. 

The  ])atient  was  in  perfect  health  until  six  weeks  before  admission,  when  she 
was  taken  with  chills  and  fever  just  as  she  was  getting  over  a  "cold."  At  the  same 
time  she  developed  an  "ear-ache."  for  which  she  applied  to  the  dispensary  for 
treatment.  The  drum-head  was  incised  and  the  ear  has  been  discharging  ever 
since.  Three  days  before  admission  to  the  hospital  she  developed  a  great  deal  of 
pain  and  tenderness  over  the  left  mastoid  area  with  frontal  headache  and  another 
rise  of  temperature. 

The  general  physical  examination  at  the  hospital  was  practically  negative,  with 
the  exception  that  she  Avas  dull  and  mentally  apathetic.  She  looked  pale  and 
waxy  and  considerably  beyond  the  age  she  stated,  namely,  30.  There  was  no 
weakness  in  either  extremity.     Sensation  was  normal  tlirnugliout  the  body.     All  the 


PATHOLOGIC  CASES  ANALYZED  391 

reflexes  were  normal.     The  teeth  were  bad  and  the  gvuns  exuded  pus.     Chest  and 
abdomen  negative. 

An  eye  examination  by  Dr.  La  Fever  showed  the  media  to  be  clear,  the  veins 
very  tortuous,  the  cups  closed  but  no  gross  changes.  Myosis  was  unequal,  the  reac- 
tions being  more  than  normal.    There  was  a  suggestion  of  a  beginning  optic  neuritis. 

The  urine  examination  revealed  a  trace  of  albumen  and  many  hyaline  ca-sts. 

The  blood  shows  9400  leucocytes  and  70  per  cent,  poly-moiphonuclear  cells. 

The  day  following  her  admission  to  the  hospital  the  pulse  became  slow  and  the 
temperature  rose  to  101°.  The  patient  was  restless  during  the  night  and  she  had 
auditoi-y  hallucinations. 

The  accompanying  chart  (XXXVI)  contains  the  data  of  the  vestibular  ex- 
amination. 

It  will  be  noted  that  stimulation  of  both  horizontal  semicircular  canals  produced 
practically  normal  nystagmus  and  vertigo  with  past-pointing  and  falling.  Stimu- 
lation of  the  vertical  semicircular  canals  of  each  ear  produced  no  reaction  what- 
soever. 

The  hearing  was  normal  on  the  right  side  and  was  impaired  on  the  left.  This 
deafness,  however,  was  of  the  middle  ear  type,  the  left  cochlea  being  normal. 

There  was  a  considerable  amount  of  purulent  discharge  in  the  left  ear  which 
exuded  with  every  pulse  beat  through  an  opening  in  the  drum-head.  The  superior 
posterior  wail  of  the  external  auditory  meatus  was  boggy  and  depressed.  The 
mastoid  was  edematous  and  tender. 

It  was  evident  that  we  were  dealing  in  this  case  with  more  than  an  ordinary 
mastoiditis.  The  varying  pulse,  the  rising  temperature,  the  general  apathy  and 
listlessness,  the  frontal  headache  and  hallucinations — all  suggested  that  Ave  were 
dealing  with  some  fonn  of  an  intracranial  involvement  complicating  the  mastoiditis. 
The  microscopic  findings  of  the  spinal  fluid  as  well  as  the  entire  clinical  picture  ex- 
cluded meningitis.  The  low  differential  cell  count  and  the  absence  of  chills  and 
fever  made  thrombosis  of  the  lateral  sinus  extremely  improbable.  The  most  likely 
condition  was  a  collection  of  pus  within  the  cranial  cavity.  The  diagnosis  re- 
solved itself  into  a  differentiation  between  a  cerebellar  and  a  tempero-sphenoidal 
lobe  abscess.  The  cerebellum  was  excluded  as  the  seat  of  the  abscess  by  the  fact  that 
stimulation  of  the  labyrinth  produced  nonnal  past-pointing  of  both  arms  in  both 
directions.  The  exclusion  of  the  cerebellum  naturally  pointed  to  the  tempero- 
sphenoidal  lobe  as  the  seat  of  the  abscess.  This  was  further  corroborated  by  the 
absence  of  reactions  on  stimulating  the  vertical  canals  of  each  ear.  Normal  hear- 
ing and  normal  reactions  from  the  horizontal  canals  indicated  that  the  labyrinths 
themselves  were  normal.  With  normal  vertical  semicircular  canals  the  absence  of 
responses  to  stimulation  had  to  be  accounted  for  by  an  interference  with  their 
nerve-pathways  within  the  brain-stem.  These  fibres  are  found  within  the  floor  of 
the  IV  ventricle,  and  any  increase  of  pressure  in  that  region  could  easily  interfere 
with  the  function  of  these  pathways.  An  abscess  in  the  tempero-sphenoidal  lobe 
could  produce  such  an  increase  of  pressure  within  the  IV  ventricle. 

Operation  by  Drs.  Fisher  and  Watson  revealed  a  necrotic  mastoid  with 
involvement  of  the  tegmen  antrae.  Another  incision  was  made  in  the  scalp  above 
the  left  ear  parallel  to  the  temporo-sphenoidal  fissure  and  the  temporo-sphenoidal 


392  EQUILIBRIUM  AND  VERTIGO 


CHART  XXXVI  A 

Name   -U^^  -^^  Age  3o  Date    C/^^/''^^l' 

Address  ,    ■  n 

Referred  by  j}{c .  (^jiy^^yo^  «,9^4Uy6C2i-^ 


DIAGNOSIS: 


SUMMARY: 


Complains  of -^-d'"-"'  (^^-^^^--^i^JL  c>^,^^  xmC^-c-  ^i^  -ca^ .    /aJ^    2i..>nZCcjt    ^«^cxi^*<..    J'o, 


HISTORY: 

Dizziness      "-^-t^. 
Staggering    ?!<». 
Deafness     ^9't^,  -'^'^  ^'°-^. 
Tinnitus     ,2^^  ^^^y^  £a^. 


NOSE 


:       \L/rji^  CL/CiM-t^ 


THROAT:    xi<A-<'^£<^    -o,^.^^^.^:<Xiiu 

BARS:               /  j> 

A.  S.  »/^.  /,     t>^AjLa-^^^  &L..^uA.c.^  ^  a,„..aj2.    ,yr'A£^    ajU^~&JJly  -d^Ajiyl.t.t^JL 

FUtula    ^^  lUtlZd, 

Hearing  Tests  ^ 

Al/           Al6  Ac>Bc=n              Poll                 c«l'Vo--«ll      Gait  I         

"1/                 1*^  Ac     <      Be     >     n                       I                      1'^.^,-rf.               '          2*Jut-^^ 


PATHOLOGIC  CASES  ANALYZED 


393 


CHART  XXXVI  B 


NYSTAGMUS 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 

Shoulder  from  above 


POINTING 


RIGHT 


Looking  to  RIGHT      ^ 

Looking  to  LEFT   Jf-^ 

Nystagmus     ^<'«^ 
Looking  UP       T  .Vertigo     >^ 

__      flA^,>i^*-^-l>ast-pointing    V 
Lookini'DOW'Nf "f  "f  ^u-  Falling 

-       /  Romberg     -^  Am^j-o^^^a^  , 

Turning  head  to  right  ?!*-<-  'Xi^CH^ 
Turning  head  to  left  >^  ^ti:^JU- 
Attempt  to  overthrow     ^^  Xt'tSCt^ 


LEFT 


To  RIGHT 


-^> 


Amp.    ^ImyJi 
Duration  3oSec. 


To  LEFT    < 

Amp.   ^,»-B-d- 
Duration  3oSec. 


TURNING 


To  RIGHT 
ShoiJder  from  above 


Nystagmus  ^f'v^'M^t*^ 
Vertigo   J^^^ju,.^ 
Past-pointing    ^..►^^-^w^. 


To  LEFT 
Shoulder  from  above 


Nystagmus  — ^o-i^^^t^ 
Vertigo  «y^-i^u»^ 
Past-pointing    »/^.»-u— <l^ 


V-(/uJ  jL/L^a 


/;?"to/^ 


■Vutir 


"-; 


^■'to. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


Douche  RIGHT  ^^-^v^ 
Amp. 
After  j/-  min.        sec.  . 


jt-io'^c'/U  <^^[^:u/^u. 


Past-pointing   i^«Xca^ -^-^^^-^-^ 
Falling  ' 


Head  Back   — > 

Amp.   -^o-o-tA 

Doifche  LEFT    ^„^^ 
Amp. 
After  //I  nun.       sec. 


Head  Back  ^— 
Amp.    ^iv«-dL 


Douche  LEFT 
Shoulder  from  above 


Nystagmus 
Vertigo 
Past-pointing 
Falling 


^••to/^ 


-/"to  Xy;^ 


f  ••  /r^./^     ^  ♦  ^5^^  <lCr 


394  EQUILIBRIUM  AND  VERTIGO 

lobe  exposed.  The  brain  was  probed  in  several  directions  but  no  pus  found.  On 
the  following  day,  however,  there  was  a  large  quantity  of  pus  on  the  dressiog, 
which  evidently  had  made  its  way  through  tlie  opening  made  at  the  time  of  opera- 
tion.    After  a  very  stormy  convalescence  the  patient  made  a  complete  recoverj*. 

Comment 

This  case  well  illustrates  the  value  of  the  examination  of  the 
vestibular  apparatus  in  cases  of  ear  suppuration  with  intracranial 
symptoms.  The  clinical  picture,  while  excluding  many  forms  of 
intracranial  complication,  distinctly  pointed  to  an  abscess.  The 
clinical  symptoms  themselves,  however,  gave  no  clue  as  to  its  defi- 
nite location ;  it  could  have  been  in  the  cerebellum  just  as  well  as 
in  the  tempero-splienoidal  lobe.  Since  the  ear  suppuration  was  on 
the  left  side  a  strong  point  against  tempero-splienoidal  lobe  in- 
volvement was  the  absence  of  aphasia.  The  presence  of  hallucina- 
tions was  of  no  great  diagnostic  value,  since  we  had  no  means  of 
knowing  whether  the  woman  was  sane  or  insane  (no  history  was 
obtainable  from  her  or  from  any  of  her  relatives  which  could  have 
shed  any  light  on  this  subject).  The  chances  are  that  the  phy- 
sician would  have  operated  over  the  tempero-splienoidal  lobe  any- 
way simply  for  the  reason  that  otitic  abscesses  are  more  frequent 
in  that  portion  of  the  brain,  but  at  best  it  would  have  been  only  a 
good  guess. 

Case  24. — Emil  K.,  age  14.  Patient  was  admitted  to  the  Jefferson  Hospital  on 
August  9,  1915,  to  the  sei'vice  of  Drs.  Dercum  and  George  E.  Price  (through  whose 
courtesy  this  case  is  reported),  complaining  of  a  paralysis  of  tlie  left  side. 

Family  history  negative. 

Patient  was  in  excellent  health  until  six  years  ago,  when  it  was  noted  that  he 
could  not  raise  his  left  arm  from  the  side.  This  partial  loss  of  function  of  the 
left  aim  persisted  until  two  years  ago,  when  he  was  operated  on  at  the  Episcopal 
Hospital  with  the  hope  of  restoring  function.  This  was  partially  successful,  but 
in  a  short  time  the  condition  relapsed  and  for  the  past  year  and  a  half  it  was 
gradually  becoming  worse.  His  left  leg  became  affected  four  weeks  ago,  and  he 
has  been  unable  to  walk  since  then.  For  the  past  two  weeks  he  has  vomited  almost 
every  day,  especially  in  the  morning.  The  following  is  a  report  of  the  physical 
examination  made  on  admission  to  the  hosi)ital :  "Well  nourished  and  developed 
boy.  Some  exophthalmus  of  the  left  eye.  Pupils  unequal.  On  showing  the  teeth 
the  mouth  is  drawn  to  the  right  side.  The  tongue  is  protruded  toward  the  left. 
Heart,  lungs  and  abdomen  normal.  Paralysis  of  the  left  upper  and  lower  ex- 
tremities.    Both  knee  jerks  increased.     Double  Babinski." 


PATHOLOGIC  CASES  ANALYZED  395 

Blood  examination  normal.    Wassermann  negative. 

X-ray  Report. — Suggests  internal  hydrocephalus;  the  clinoid  processes  are  ill- 
defined. 

Eye  Examination. — Reaction  to  light  and  convergence.  0.  D.,  none.  0.  S., 
slightly  to  light,  but  not  to  convergence.  There  are  coarse  nystagmic  movements 
when  the  effort  is  made  to  converge.  There  is  slight  dissociation  of  ocular 
movements,  although  the  binocular  function  is  maintained.  Rotation  is  limited  in 
all  directions,  but  more  sharply  limited  upward  and  downward. 

Ophthalmoscopic. — 0.  D.  media  clear;  the  disc  margins  are  bhirred;  the  cup 
is  filled  in;  nerve  markedly  pale  on  the  temporal  side.  Veins  are  tortuous  but  not 
full,  the  arteries  are  slightly  contracted  and  there  are  no  hemorrhages  in  the  retinal 
fiedd.  0*  S.  media  are  clear;  disc  margins  are  hazy;  disc  pale  throughout;  the  cup 
is  filled  in.  The  arteries  are  contracted.  Pigment  is  in-egularly  distributed  in  the 
fundus,  no  white  spots  in  retina.  The  atrophy  of  the  nerve  is  more  marked  in  the 
left  than  in  the  right  eye. 

Diagnosis. — Optic  atrophy  and  a  partial  ophthalmoplegia. 

The  findings  of  the  ear  examination  are  recorded  on  the  accompanying  chart 
(XX'XVII).  It  will  be  noted  that  there  was  no  interference  with  or  absence  of 
any  of  the  responses  from  stimulation  of  both  ears  by  turning  and  douching.  This 
would  indicate  an  intact  vestibular  apparatus  throughout.  The  only  abnormality 
noticed  were  hyperactive  responses  in  nystagmus,  vertigo  and  past-pointing.  The 
following  report  was  made : 

(1)  Both  labyrinths  and  VIII  Nerves  are  normal.  The  impaired  hearing  in 
the  left  ear  is  not  due  to  involvement  of  the  labyrinth  or  the  VIII  Nerve,  but  to  a 
chronic  catarrhal  change  in  the  left  middle  ear. 

(2)  The  medulla  oblongata  and  pons  (the  brain  stem)  would  appear  to  be 
normal  because  of  the  normal  nystagmus  obtained  on  stimulation  of  the  hori- 
zontal and  vertical  semicircular  canals  of  both  ears. 

(3)  The  right  cerebellar  hemisphere  would  appear  normal  because  the  right 
arm  past-pointed  correctly  both  to  the  right  and  the  left  after  stimulation. 

(4)  The  left  cerebellar  hemisphere  could  not  be  tested  because  of  the  paralysis 
of  the  left  side  of  the  body. 

(5)  The  fact  that  the  left  VIII  Nerve  is  normal  would  strongly  suggest 
that  there  is  no  tumor  in  the  left  cerebello-pontile  angle. 

(6)  All  the  responses  in  nystagmus,  vertigo  and  past-pointing  on  stimulation 
of  both  ears  were  strikingly  hyperactive  which  would  suggest  an  irritation  of  the 
posterior  fossa  contents  by  some  lesion  above  or  anterior  to  the  tentorium. 

A  decompression  operation  was  done  without  revealing  any  tumor. 

The  patient  died  and  the  autopsy  report  by  Dr.  E.  H.  Funk  was  as  follows: 
"A  roughly  oval  tumor  about  8  cm.  by  6  cm.  by  6  cm.  springs  from  the  inner 
surface  of  the  right  hemisi)here  of  the  brain.  It  is  rather  finnly  attached  by  its 
under  surface  to  the  corpus  callosum  and  by  its  outer  surface  to  the  wall  of  the 
lateral  ventricle.  Its  upper  and  iimer  surfaces  are  smooth  and  at  points  cystic  in 
consistency.  The  inner  surface  of  the  skull  is  quite  rough  and  irregular  and  ap- 
pears to  be  thicker  at  some  points  than  at  others.     The  dura  is  normal  in  appear- 


396  EQUILIBRIUM  AND  VERTIGO 


CHART  XXXVII  A 


Qnx^  yj(\  Kgt/'A  Date   ^aV/^/^ 

dress  ^^      ^  ^    /--)  /        ' 


Name 

kddress 

by 


Referred  by  S^-r    Uto     &■    ^ 


DIAGNOSIS: 


SUMMARY: 


of     Qu^^A^    y     ^   '^'-^ 


Complains 


HISTORY: 

Dizziness  ^■ 
Staggering  {/£-«/ 
Deafness  .^ervJL. 
Timiitus    ^^ 


NOSE:     .y^^^oXl^ 
THROAT:    -^^C*^-««^^*^ 


A.  D.     JI'^'J^  ^^^ 


Fistula 


Hearing  Tests 

A 

A 

Ac 

Be 

— 

Ac 

Be 

Pol.  I  c*  I  Gait  I 


PATHOLOGIC  CASES  ANALYZED 


397 


CHART  XXXVII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 


NYSTAGMUS 
Looking  to  RIGHT  -^■-'^^^ 
Looking  to  LEFT  JtjnJL 


SPONTANEOUS 


Shoulder  from  above 


POINTING 


RIGHT 


Looking  UP 

Looking  DOWN    >^' 


Nystagmus  <~-'r»vJ. 

Vertigo  -//>».\jt- 

Past-pointing    ^-•~-*-' 

Falling   ^^  tUJtZiL 
^^       Romberg    A^^  titXZ^ 

Turning  head  to  right   ^-»^    tey^^l^ 
Turning  head  to  left    JhtU-  :^Ji^CfL/, 


«-'"<•-=>-■'-—,    ^^y^^^—     'I  Turmng  head  to  lelt    i/A*<.  Xjc^i^t^ 

t^,r^^ivr<    4.,*-.^  y^H,^^uyJ^aA^ .    Attempt  to  overthrow  ^^  -tUitZ^L 


To  RIGHT    > 

Amp.  -Vi^^E- 
Duration  3  3  Sec. 


To  LEFT      < 

Amp.  <cu\^t, 
Duration  S^Sec 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus  "^*7? 
Vertigo 
Past-pointing        " 


Vt/cJCi^ 


To  LEFT 
Shoulder  from  above 


Nystagmus  Gmm^Mu^^cJ- 

Vertigo  •> 

Past-pointing         <• 


LEFT 


I     iaxA&^M^ 


CALORIC 

Douche  RIGHT   ^~\ 

Douche  RIGHT 

Amp.  %iy»J- 

Shoulder  from  above 

S-^-M^ 

\o                   / 

After        min.  VJ'sec. 

1 
Nystagmus  Jl' t/VujuxJl^ 
Vertigo   J^4y'u^»JL 
Past-pointing  ^tJt.Mt~*l 
Falling     Jh»^A,„.<kjL 

Head  Back    yf-U  itutldL 

to 

to        X 

Amp. 

Douche  LEFT     1^ 

Douche  LEFT 

Amp.  -ScM^/- 

Shoulder  from  above 

<f-  to-C^ 

to/            \ 

After        min.  ^  sec. 

Nystagmus  •yrv^ut^aX^ 

Vertigo    ^,/uuAijL 

Past-pointing    ^.^^u^*^ 

Falling     Ji-^^^^f 

Head  Back  ^^'j^Tt/ 

to 

/  to 

Amp. 

\ 


398 


EQUILIBRIUM  AND  VP:RTIG0 


ance.  The  pituitary  body  was  torn,  but  showed  no  gross  lesion.  The  sella  turcica 
is  normal  and  the  cerebral  vessels  are  normal    (Fig-s.  122  and  123). 

Case  25. — Arthur  P.,  age  25.  The  patient  was  referred  to  the  hospital  of 
the  University  of  Pennsylvania,  from  St.  Paul,  Minn.,  with  a  diagnosis  of  a  cere- 
bellar lesion.  He  was  admitted  to  the  hospital  on  January  3,  1916,  with  the  chief 
complaint  of  headache,  vertigo  and  failing  vision. 

Illness  began  four  months  before  admission  with  a  sudden  flashing  of  colors 
before  the  eyes,  accompanied  by  headache,  which  lasted  over  night.  These  symptoms 
reappeared  a  week  later.  The  headache  began  to  come  on  with  greater  frequency 
and  lately  he  has  had  a  headache  eveiy  day.  The  headache  extends  across  the 
frontal   region   through  the  temporal  bone  to  the  occipital   region,  even   down   to 


Fii;.    122. — Tumor  of  corpus  callosuni. 


the  back  of  the  neck.  During  the  past  month  he  has  had  double  vision,  also  vertigo 
on  arising  in  the  morning,  which  would  last  for  about  an  hour.  Very  frequently 
when  the  headache  is  very  severe  it  is  accompanied  by  vertigo.  During  the  past 
month  patient  also  finds  it  very  difficult  to  walk  in  a  straight  line.  He  has  been 
too  weak  to  be  about  of  late  and  he  is  mostly  confined  to  bed.  Several  weeks  ago 
there  appeared  vomiting  spells  which  had  no  relation  to  ingestion  of  food.  The 
stomach  contents  have  occasionally  shown  traces  of  blood. 

The  patient's  brother  stated  that  15  years  ago  the  patient  received  a  severe 
blow  in  the  centre  of  his  forehead  which  rendered  him  luiconscious  for  several 
hours.  The  brother  also  thinks  that  the  patient  is  losing  his  memory  and  mental 
power. 


PATHOLOGIC  CASES  ANALYZED 


399 


400  EQUILIBRIUM  AND  VERTIGO 


CHART' XXXVIII  A 

Name   ^^«^^   ^  Age  ^IS^  Date^^/.  <^-  /f /^ 

Address  „         - .     « /     /  -^ 

Referred  by    lAv^^^^\A>i^^  tJfir^AZ^a^ 

/ 

DIAGNOSIS: 


SUMMARY: 


o,  ^v- /^-^  ^  V' '^'"^'^' 


Complains  of  -Z-*^-^,   ^™~ 

HISTORY:  . 

Dizziness  v?-*-^ 
Staggering  if**' 
Deafness  ^.,-wv^. 
Tinnitus     ^.nu^ 


NOSE: 


sJt'*^      JL'^O'.'MA.AyX.cA^^ 


A 
EARS: 

A.  S.  tfjixt^*/  >c<i 


THROAT:      ^^-  itv a^^-l.**-*-* 

Fistula    w^^   :tiyaXZjL 

Hearing  TesU  ^      /»  ,    ,    <7  -^t^v 

AU  A.|r  Ac<       Bc=n  Pol.  I  <=M/'*^       Gait    .  iT  ^ 

=  I  ^  U  Ac    <      Be     =      n  1  l-V-^  I  •  y  _ 


PATHOLOGIC  CASES  ANALYZED 


401 


CHART  XXXVIII  B 


>fYSTAGMUS 

Looking  to  RIGHT    -^''^^ 
Looking  to  LEFT  -^aViM/ 
Looking  UP       * 
Looking  DOWN  Jh-<ni^ 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 

Shoulder  from  above 


POINTING 


RIGHT 


J-'AJ^it-  /  '■ /i  T^CyHc- 


Nystagmus  l/-i^i^'^  ^> 

Vertigo   ■a^    ^tZM^tA^ 

Past-pointing  l^'.-aMA-  <«yu*t.  ;Z^  J^/i^ 

Falling    ,4-,^^  ' 

Romberg    ^muA/  JUj>-<^-^^a. 

Turning  head  to  right   ^^V-t^    *i-*--^  .-t-.-i.A-' 

Turning  head  to  left  .. 

Attempt  to  overthrow  C/x,/i*vo  atA-J-i^ 


.^. 


LEFT 


i  fiA^A^aX^- 


TURNING 

To  RIGHT    ^  To  RIGHT 

Amp.  "C*^  ''  Shoulder  from  above 

Duration  c5f^  Sec. 

Nystagmus  iQ.*yu^e^uU.a^ .t^a^^i^'^*^^^^ 

^fix  ixM-  ^^iijtA**ajL  A't.4^Z*<,  Vertigo   S-yKt-^4  aa-oXju^  ^ 

>-»v*«^  /£.»~m^\/Aj  -  Past-pointing   /X*yiujti*,<:l.*^.*^y , 

To  LEFT      - 


J'^-to5?,^(L-/-?"to;^.^«;r. 


:/?^-^M- 


'•*-*«-<•  v-fc'w 


Amp.  <a/i«<. 
Duration  Z$  Sec 


To  LEFT 
Shoulder  from  above 


Si'tofy', 


Nystagmus  A  ci^-f/io-C*/^  XM^^'i' 
J.    J  Vertigo  t^a^aiA^oja^ 

A^^iCr        Past-pointin/  %Xu*au.-o 


yiy     X</i^ 


l'^'U>^K^ 


Douche  RIGHT  ^jn^A^ 
Amp. 
After   -y^  min.        sec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


^ "  to-j^^y 


,^4/ 


Head  Back    ^. 

Amp.  <«-->»-<, 

Douche  LEFT   ^ 

Amp. 

After    /  min    /o  sec. 


Head  Back 
Amp. -Ca 


Nystagmus  ^^•*-m--£-- 
Vertigo  yj-j,^^.,^^ 
Past-pointing   ^.^.-u^^^i/. 
Falling  c^,,.!..,.,^ 


Douche  LEPT 
Shoulder  from  above 

Nystagmus     -piAAMAZtJ. 
Vertigo  Jh<r''UAjL.oJ. 
Past-pointing   tyo^fM^i^Zy 
Falling    Jh.^,^.u^" 


f" 


/;J' 


to;^,^/lj- 
to4^ 


"^ 


/.2"to/t^ 


"  tov'B^^tr 
/o"to7^-^^- 

/J'to^^- 


yi 


'\okJ* 


^m 


402  EQUILIBRIUM  AND  M:RTIG0 

I'revious  nietlical  liistorv  })ra('tic;illy  negative.     Denies  specific  infection. 

I'Jn/sical  Kxaminatipn. — Patient  fairly  well  nourished.  No  facial  paralysis  or 
disturbance  of  sensation.  Ketiexes  everywhere  present  and  apparently  normal. 
Finger-to-nose  test  negative.  Sense  of  suiell  undisturbed.  No  ankle  clonus  or 
Babinski.     Extremities  normal,  examination  of  chest  and  abdomen  negative. 

Wassermann  reaction  negative.  Lumbal-  puncture  shows  the  spinal  lluid  under 
pressure  of  15  m.m.  of  mercury.     The  fluid  is  clear. 

Eye  Examinaliun  by  Dr.  de  Scliireinitz. — Pupils  respond  to  ordiiuuy  stinudi. 
There  is  distinct  limitation  of  the  outward  movement  of  each  eye.  No  hemianopsia. 
Right  eye:  there  is  an  exceedingly  vascular  choked  disc  of  4^2  diopters.  Many  of 
the  hemorrhages  suggest  the  presence  of  thrombi.  Left  eye :  the  disc  is  choked 
but  much  less  elaborately;  the  upper,  lower  and  nasal  edges  are  thinned,  the  thick- 
ness of  the  disc  is  about  3  diopters.     There  are  no  hemon-hages. 

Exaniinaticm  of  urine  and  blood  are  negative. 

An  examination  of  the  vestibular  apparatus  was  made  on  Januai-y  5,  1916, 
and  the  findings  recorded  on  chart  (XXXVIII).  It  will  be  noted  that  the  hearing 
is  normal  in  both  ears. 

(1)  The  presence  of  a  spontaneous  vertical  nystagmus  ujiward  suggests  an  in- 
terference within  the  brain-stem. 

(2)  The  spontaneous  past-pointing  of  the  right  arm  suggests  a  right  cere- 
bellar disturbance. 

(3)  The  absence  of  nystagmus  on  douching  the  right  ear  with  the  head  in  the 
"so-called"  upright  position  indicates  an  interfei'ence  with  the  nerve-pathways  for 
eye-movement  within  the  right  pons. 

The  most  striking  feature  of  the  entire  examination  is  the  marked  jiast-pointing 
of  each  arm  to  the  right  and  left.  This  suggests  that  the  cerel)ellum  is  intact.  The 
exaggerated  past-pointing,  however,  could  only  be  accounted  for  by  a  supratentorial 
lesion  irritating  the  cerebellum  by  pressure. 

Pressure  from  such  a  lesion  could  easily  account  for  the  absence  of  nystagmus 
when  the  right  vertical  semicircular  canals  were  stimulated,  also  for  the  perverted 
nystagnuis  from  the  left  vertical  canals  as  well  as  for  the  paretic  condition  of 
the  external  recti  muscles. 

The  following  report  was  made:  "The  ear  examination  suggests  normal  laby- 
rinths and  VIII  Nerves,  noi-mal  cerebellum  and  brain-stem.  The  hyperactive 
responses,  chiefly  those  in  past-pointing,  suggest  pressure  u]ion  the  cerebellum 
from  above  the  tentorium." 

Patient  had  a  decompression  operation  with  a  puncture  of  the  corpus  colossum 
on  January  8,  191G.  Following  this  the  patient  was  improved  and  went  home. 
The  patient  died  on  February  8,  and  liis  family  i)liysician  reported  that  the  autopsy 
showed  a  tumor  situated  on  the  left  side  of  the  i)osterior  apex  of  the  occipital  lobe 
of  the  cerebrum.  Tliere  was  consideral)le  destruction  of  the  l)rain-tissue,  and  the 
cavity  had  worked  forward  and  had  almost  broken  into  the  left  ventricle. 

Case  26. — Mr.  J.  H.  M.,  age  58.  The  patient  was  admitted  to  the  University 
Hos]iital  on  June  10,  1015,  with  the  chief  com]ilainl  of  staggering,  vomiting  and 
tinnitus. 

The  tro'.ible  dales  back    foui'  vears,  when  he  began  to  have  a  buzzing  in  his 


PATHOLOGIC  CASES  ANALYZED  403 

left  ear,  following  which  the  hearing  became  considerably  impaired.  This  impair- 
ment of  hearing  progressed  steadily  and  quite  rapidly,  so  that  now  he  is  prac- 
tically deaf.  Last  sunmier  he  began  to  stagger.  He  has  never  had  any  headache, 
but  in  the  past  six  months  he  has  vomited  off  and  on.  The  vomiting  is  not  pre- 
ceded by  nausea,  but  is  followed  by  retching.  He  has  been  rapidly  failing  in  the 
last  two  months,  particularly  in  the  last  two  weeks. 

The  previous  medical  history  is  negative. 

He  denies  any  venereal  history. 

Physical  examination. — Station  poor,  falls  toward  the  left.  In  walking  he 
staggers  both  ways,  but  more  to  the  left.  Adiadokokinesis  more  marked  with  the 
left  hand.  Marked  ataxia  in  finger-to-nose  test  with  left  hand  especially'.  Some 
tremor  and  h3'permetry  with  both  hands.  Sense  of  smell  good.  The  V,  IV,  IX,  X 
and  XI  cranial  nerves  appear  to  be  uninvolved.  Tliere  is  a  slight  weakness  possibly 
of  the  lower  division  of  the  right  VII  Nerve.  There  may  be  a  slight  weakness  of 
the  grip  in  the  right  hand.  Sense  of  muscular  position  in  upjDer  extremities  ap- 
pears to  be  normal.  Biceps  jerks  very  good.  Sensation  present  over  entire  body, 
although  it  seems  to  be  slightly  delayed.  There  i.s  no  spasticity  of  the  lower  limbs. 
Knee  jerks  prompt;  no  ankle  clonus  and  no  Babinski  on  either  side. 

Examination  of  chest,  lungs,  heart  and  abdomen  negative. 

Eye  examination  by  Dr.  dc  Scliweinitz  shows  a  choked  disc  of  6  diopters 
on  the  right  side  and  7  diopters  on  the  left  side.  Pupils  arc  equal,  react  normally 
to  light  and  accommodation.     There  is  no  hemianopsia. 

Examination  of  the  urine  and  blood  negative. 

Examination  of  the  vestibular  apparatus  was  made  on  June  21,  191o,  and  the 
findings  recorded  on  accompanying  chart   (XXXIX). 

It  will  be  noted  that  the  hearing  in  the  right  ear  is  normal;  the  left  ear  is  stone 
deaf.     Among  the  spontaneous  phenomena  we  have: 

(1)  Marked  nystagmus  on  looking  to  the  right. 

(2)  Weakness  of  the  right  and  left  internal  recti. 

(3)  A  spontaneous  past-jininting  of  the  right  arm  to  the  left. 

(4)  Spontaneous  falling  to  the  left  Avith  a  stiff  jjelvic  girdle. 

The  turning  test  suggests  a  non-functionating  left  labyrinth  because  the  nys- 
tagmus after  turning  to  the  right  lasted  16  seconds,  whereas  after  turning  to  the 
left  it  was  of  23  seconds'  duration.  There  was  also  an  absence  of  past-pointing  of 
the  left  arm  to  the  left. 

Douching  the  right  ear  i)roduced  prompt  responses  from  the  vertical  semi- 
circuilar  canals  as  well  as  from  the  horizontal  canal.  The  nystagmus,  however, 
was  inverse;  that  is,  it  was  in  a  direction  opposite  to  what  it  ought  to  be,  namely, 
to  the  right  instead  of  to  the  left.  The  nystagmus  was  also  perverted,  that  is  the 
wrong  kind — horizontal  instead  of  rotary — when  the  vertical  canals  were  stimulated. 

Douching  the  left  ear  produced  practically  no  responses  at  all. 

In  attempting  to  analyze  these  findings  due  attention  must  be  paid  to  the  dif- 
ferentiation between  a  central  and  peripheral  lesion.  The  chief  complaint  in  this 
case,  namely,  staggering,  which  was  ushered  in  by  tinnitus  and  gradually  increas- 
ing deafness,  would  suggest  a  peripheral  lesion.     This  would  apjiear  to  be  corrobo- 


404  EQUILIBRIUM  AND  VERTIGO 

CHART  XXXIX  A 

-ajjL_<^  ^  Age  «?<r  Date    y^..^  -(/,  /9/j- 


Address"  ^  /  ^'  "  LFaiey.x^  ^/,   /^,j 


rets  / 

Referred  by    tU^'i-^-^yt^J^   'M^<JuZk£. 


DIAGNOSIS: 


SUiMMAR-i- 


Complains  of     cfe^ 


f^^^*^  '    '^^*^'**^^^^^^,  ■tl^'^^-^.^Ji-<i^  ,  -t>o-i-»I2IILo 


HISTORY: 

Dizziness      ■J\jO' 
Staggering    }jc^ 
Deafness     ^.e^ 
Tinnitus      if.^^ 


NOSE:  Jhl. 

THROAT:     .^hU 


A 
EARS: 


Fist 


ula      yia^     Zjt-ljfZ-4. 


Hearing  Tests 

A|/  A|^  Ac     <      Ho     >     n  PoI.I  c' 1^^^         r.,U  I  ^^-^ 


Ac     o       Be     o       n  I  _ 


V^    ..™    .^^^/-..^    _  ^^  ^  __^    ^j^   ^_^ 


9^C^-*^ZZUa 


PATHOLOGIC  CASES  ANALYZED 


405 


CHART  XXXIX  B 


.WSTAGMUS 
Looking  to  RIGHT    ^O 
Looking  to  LEFT  ^.r^^ 
Looking  UP     ^ 
Looking  DOWN  -/^,n^ 


^Ui  ^^  -t^*^' 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 

■*<-****^  1 1       Shoulder  from  above 


RIGHT 


POINTING 

LEFT 


Nystagmus  'RCC^a^  r^  Ze.A.....y  ^.^-^^  .^v-^    ^  ?rio/iz" 

Vertigo    A<n.^ 

Past-pointing  T^t-al^  ,«*..-.-  ;fe"  <<!i^ 

Falling     iZ   CUi 

Romberg  j^r^M*.  Xi  ^t/t-  cu-t.«-  ,t.Jl/.  ^i^  <jy^»-^ ,  y^-m.  /-.  j^^jf 
Turning  head  to  right  tuLd^^A^  t^  lui-    L^^^^^-M  ■ 
Turning  head  to  left  .,      '     -        ••  ■• 

Attempt  to  overthrow  ^j^^^  AajI-^  ^-"^"^^  x-**-*.--' 


<l/^    ^^ccC'^<-^^''*<' . 


To  RIGHT    — 5» 

Amp.  "^o-ft^ 
Duration  /i  Sec. 


TURNING 


To  RIGHT 
Shoulder  from  above 


Nystagmus  p^rtuJicaMtJ   )t«'u«^,  tJXjr^i.  *X»«zi---<-<t 
Vertigo  Jx^om^      ' 
Past-pointing    >1'A<4<jJI. 


lo"  toT^c^ix  /rtoli^U 


To  LEFT  -^ 

Duration   33  Sec. 


To  LEFT 
Shoulder  from  above 

/    ! 

Nystagmus    -^»A.«**-i 

Vertigo    JI~.,/i...A.cJi 

Pa:st-pointing    aJL<j^^    ^    KtM- 


/X'  to  /T^ 


'^J^/^i.xJM^ct. 


Douche  RIGHT    -^ 

Amp.  3»-«-«< 

After         min.  S-Tsec. 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


7C^>t«U4      ^UAA.jeM^r\A^ 


Nystagmus   /*t>u^^^Z»^  ^u.^   t^Ar-iA.*^- 
dL  1L^..^JL  Vertigo   J^^^^m^^J^ 

Past-pointing  ^^vu-.oi£. 
Falling    jf-^M^^^rdt' 

Head  Back    < '"^"^^  ,*t«AitZ;i>vL. 

Amp.  <*-'^ 


Douche  LEFT 
Amp. 
After         min.  V^sec. 


^. 


'AjXoA^ 


Head  Back  «/ 
Amp. 


AA.^^ «£.£BL.y.         /ii-.'^f  ^T*  MT.a_ 


Douche  LEFT 
Shoulder  from  above 

Nystagmus  /t>A,c~^Xi.iJi^  ,«>-«*c>/ 
Vertigo    CLa^ul^^  i 

Past-pointing  ^LCtju^ 
Falling  ili-LA^U 


(^  •■toT?.;^ 


/"  to^f^^ 


<^^to^*/Ct^. 


(^ua^^j^ 


4"to  ;^c^^ 

J5£"to;^.^£/- 


406 


EQUILIBUILM  AND  VERTIGO 


rated   by   the   tests,    wliicli   sliuw   a   distiiiot    involvement   of   one   ear.      This   case, 
however,  is  one  of  central  lesion,  because: 

(1)  The  unsteadiness  of  gait  and  spontaneous  nystagmus  were  scarcely  no- 
ticeable at  the  beginning  of  his  illness,  but  gradually  became  worse  as  time  went 
on.     This  is  not  the  I'ule  in  a  labvrinthine  disturbance,  in   which  the  onset  of  the 


RIGHT 


LEFT 


^[TEMPORAL 
LOBE 


Via.    124. — Tumor  of  the  left  cerebello  pontile  angle  attached  to  pons. 


various  phenomena,  such  as  staggering  and  nystagmus,  is  verj'  marked  and  ex- 
plosive, reaching  a  climax  very  quickly  and  then  gradually  subsiding. 

(2)  The  nystagmus  obtained  after  douching  was  "inverse"  and  "perverted." 
This  always  indicates  a  disturbance  of  the  brain-stem. 

(.'?)    The    i)ast-pointing    after    turning    and    douching    was    very    much    more 


PATHOLOGIC  CASES  ANALYZED  407 

marked  in  one  arm  than  in  llie  otlier.  Obvionsly  this  could  not  be  produced  by  an 
"end-organ"  disturbance. 

It  must  also  be  noted,  however,  that  douching-  the  left  ear  produced  practically 
no  responses.  This  ear  was  also  stone  deaf,  which  would  indicate  a  destruction  of 
the  labyrinth  or  the  VIII  Nerve  of  this  side.  This  case,  therefore,  presents  the 
picture  of  a  central  lesion  with  the  destruction  of  the  left  "end-organ."  Such  a 
combination  is  best  explained  by  a  lesion  in  the  cerebello-pontile  angle  (Fig.  124). 

The  question  of  actual  involvement  of  the  neighboring  structures,  namely  the 
brain-stem  or  cerebellum,  is,  of  course,  inii)ortant.  We  note  on  the  chart  that  the 
left  arm  fails  to  jiast-point  to  the  left  under  aJl  circumstances.  This  would  sug- 
gest involvement  of  the  left  cerebellar  hemisphere.  There  were  other  examinations 
made  in  this  case  on  different  dates,  however,  and  at  times  the  left  arm  did  past- 
point  to  the  left.  This  Avould  make  an  actual  involvement  of  the  cerebellar  sub- 
stance improbable;  the  failure  of  response  as  noted  is  therefore  probably  due  to 
pressure.  The  medulla  oblongata  and  pons  are  most  likely  actually  involved  by 
the  lesion  because: 

(1)  The  vertical  semicircular  canals  of  the  right  or  opposite  side  react,  which 
indicates  that  the  angle  lesion  is  not  exerting  any  great  amount  of  pressure  against 
the  brain-stem.  Any  evidence  of  brain-stem  disturbance,  therefore,  is  probably 
due  to  a  lesion  of  the  brain-stem  itself  and  not  produced  by  pressure  from  without. 

Douching  the  right  ear  produced  both  an  "inverse"  and  "perverted"  nystagmus. 

The  patient  was  oi:)erated  on  and  the  following  report  made  by  the  surgeon : 
"The  tumor  was  about  as  lai'ge  as  a  hen's  egg,  situated  in  the  cerebello-pontile 
angle  on  the  right  side  and  was  adherent  by  a  broad  base  in  the  region  of  the  pons." 

The  above  report  was  sent  to  us  in  a  letter  written  by  Dr.  George  P.  Midler, 
who  ojierated  on  the  case.  When  this  letter  was  received  stating  that  a  tumor  was 
found  on  the  right  side  we  were  rather  chagrined  to  think  that  the  ear-tests  could 
be  so  misleading.  We  then  wrote  to  Dr.  Miiller  and  jestingly  suggested  that 
he  had  operated  on  the  wrong  side;  according  to  the  ear  examination  the  lesion 
was  in  the  left  cerebello-pontine  angle  and  not  the  right.  We  were  gratified  to  re- 
ceive a  i^rompt  reply  telling  us  that  he  had  consulted  the  hospital  records  and 
found  that  he  had  made  a  mistake  in  his  letter — that  the  lesion  and  operation  were 
both  on  the  left  side  as  the  ear  report  suggested. 

Case  27. — Mr.  G.  C.  M.,  age  49.  Patient  was  admitted  to  the  Samaritan  Hos- 
pital on  April  1(S,  1915,  with  the  history  that  he  Avas  unable  to  walk  since  the  pre- 
ceding August. 

The  trouble  commenced  about  a  year  ago,  when  he  became  extremely  nervous. 
At  this  time  he  complained  of  feeling  generally  weak,  but  had  no  pain  and  no 
headache.  At  times  he  had  tremor  and  involuntary  movement.  Now,  his  speech  is 
slow  and  labored.  He  is  unable  to  write.  Is  extremely  deaf,  the  left  ear  having 
failed  seven  years  ago  and  the  right  ear  two  months  ago. 

Physical  Examination. — General  condition  very  good.  Patient  is  unable  to 
walk  because  of  inco-ordination  and  not  paralysis.  Speech  is  slurring,  indistinct 
and  of  the  bulbar  type.  Facial  movements  are  active  on  the  left  side,  particularly 
about  the  mouth.  Tongue  protrudes  to  right  side  of  middle  line,  but  is  freely 
movable.     The  left  eye  is  not  closed  as  quickly  as  the  right.     There  is  evidence  of 


408  EQUILIBRIUM  AND  \  ERTIGO 


CHART  XL  A 


Name   ^^^^   ^.  '^^  -^  Age   ^f  Date  -^  .'O,   'f"^ 

Address 


Referred  l.y  '"-^.^-  /.^— >i^   J^^-^jL^^ 
DUGNOSIS: 


SUMMARY: 


tf-jLijtu     'to    y^cJt-b. , 


Complains  of    2^^C^^^*^^,   ^..x^^^l^^^ 


HISTORY: 

Dizziness     -j^t<^ 
Staggering   ,^it^ 
Deafness    ^^:<^,   ^^^ 
Tinnitus      yj,y-,,ju   . 


NOSE:      '3/i^UiU-  .^U-^^'aX^    ZT  /^y^. 
THROAT:       A^J^.<jZJ-i^ 

EARS'  ^       / 

'  A.  S.      6^U.-la£u  AZL.^^i£^  .        j(.  (^r  Zsi^^^^c..^ . 


Hearing  Tests 

A I  A  I  Ac  Be  n  Pol.  |  c«  1  Gait  I 

=  1  I  Ac  Be  n  I  I  I 

IjUjuc^z::*.  ^o.j^  ^<^t^..***^  ^l  )..iu>-2^  'Lo^^.ctzfz..^ . 


PATHOLOGIC  CASES  ANALYZED 


401) 


CHART  XL  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 

Shoulder  from  above 


RIGHT 


NYSTAGMUS 


Looking  to  RIGHT    < 

Looking  to  LEFT  ^1^^  — ^  .f-^^y^^-^*^ 

Nystagmus  )vmM*^-  -^  x-«^  A^^oc^Z^r^^^  .t^«<^    ti  A,<^ 
Looking  UP  7  ^^-^  C  ^  A*' J^^ertigo    ^ot.*- 

Past-pointing  ■<V/*-  ^ha-ua^  ti>   C'U^ 
Looking  DOWN  If a-^  t.  j^^    Falling     ^  'R'-f^^ 

!l^^..     Romberg     l*-OU^     ti  /^^Ir. 
C>^L^  ^Wjril/  -^^.-^  Turning  head  to  right 

^  »  4        A  urning  head  to  left 

Attempt  to  overthrow 


POINTING 


LEFT 

S"    to    J^l^ 


To  RIGHT 
Amp. 
Duration 


To  LEFT 
Amp. 
Duration 


TURNING 


To  RIGHT 

Shoulder  from  abovt 


< 


Sec. 


\ 


Nystagmus 

Vertigo 

Past-pointing 


^ 


^<^- 


X.  tx^ 


Sec. 


To  LEFT 
Shoulder  from  above 


Nystagmus 

Vertigo 

Past-pointing 


CALORIC 


Douche  RIGHT  TlJ.iA  _^   r\%-*r^  Douche  RIGHT 


Amp.  3c 

After    /    min.  j~()sec 


Head  Back    — 
Amp.  Vi>.«-«6. 


Shoulder  from  above 


(^MiUtJil  3  "  to  ^^ 


Nystagmus  ■J-^JU^'^'^  rrf.^tA.^^,.,tji^  .tjt;ct.,^^^{^  iJU^u.(.JL 
Vertigo  AnJt-^  '  ' 

Past-pointing    -^•^^^ 
Falling   Jt^rmt*^ 


Douche  LEFT   X' 
Amp. 
After  i/.    min 


Head  Back     ?Mrvi.t^ 
Amp. 


Douche  LEFT 
Shoulder  from  above 

Nystagmu.s     -ViC^x..^ 
Vertigo    'A  i-^jt.^^ 
Past-pointing  ^  ^-tx^x^ 
Falling  _'^/Ut«./- 


(^/:zu^ 


OujjJLU 


^Q-^OT^-'CaL^i  ■»<.«.^ 


3"to/t/t 


3''  to  /.^ 


/aAunZCiX^ 


410 


EQUILIBRIUM  AND  VERTKiO 


some  loss  of  seusation  and  a  feeling-  of  numbness  in  I  lie  distribution  of  the  left  V 
Nei've.     Muscular  power  of  entire  body  seems  good. 

Corneal  reflexes  on  both  sides  present.     Tendon  roflexos  are  senerallv  active. 


Fig.  125. — Brain  showing  tumor  of  the  left  cerebellar  lobe  and  involving  the  cerebello  pontile  angle. 
About  1/3  of  the  inferior  portion  of  the  left  cerebellar  lobe  has  apparently  been  destroyed  and  the  5th,  7th 
and  8th  cranial  nerves  are  displaced  and  entangled  in  the  mass  of  the  tumor.  Another  small  tumor  is  shown 
on  the  surface  of  the  right  lateral  aspect  of  the  pons  near  the  cerebral  peduncle. 


Knee  jerk  and  Achilles  jerk  are  much  increased.  There  is  a  unilateral  ankle  clonus 
and  a  right  patellar  clonus.  Babinski  present  on  the  left  side,  but  doubtfully  on 
the  right.     Abdominal  reflex  diminished  on  both  sides. 


PATHOLOGIC  CASES  ANALYZED 


411 


Co-ordination  of  right  arm  is  fair.  Finger-to-nose  test  and  finger-to-finger  test 
are  defective.  Movements  of  left  arm  are  very  inaccurate,  the  hand  oscillating 
several  inches  about  an  objecr  which  he  attempts  to  touch.  There  is  marked  inco- 
ordination of  the  left  leg  and  not  so  much  of  the  right.  Has  difficulty  in  swallow- 
ing liquids,  the  same  at  time  regurgitating  through  the  nose. 

Eye  Examination. — Right  pupils  slightly  larger  than  left;  both  react  to  light 
and  accommodation.  There  is  a  spontaneous  nystagmus  in  every  direction.  No 
paralysis  of  extraocular  nuiscles.     There  is  a  double  choked  disc  of  6  diopters. 

Wassermann    negative.      An    examination    of    the    vestibular    apparatus    Avas 


Fig.    126. —  Same   specimen    as   figure    125,   showing  only   cerebellum   and   brain-stem   which   have   been 

separated  from  cerebrum. 


made  on  May  10,  lOl'),  and  the  accompanying  chart  (XL)  .shows  the  data  ob- 
tained. Although  it  was  difficult  to  determine  the  hearing  in  this  case  because 
of  the  mental  condition  of  the  patient,  nevertheless  it  was  evident  that  he  was 
gtone  deaf  in  his  left  ear.  and  that  souie  hearing  was  present  in  the  right  ear. 

Douching  the  left  ear  failed  to  produce  any  response  whatsoever.  This,  to- 
gether with  the  total  deafness  on  this  side,  indicates  a  destruction  of  the  laby- 
rinth or  the  VIII  Nerve.  Stimulation  of  the  right  vertical  semicircular  canals  pro- 
duced perverted  nystagmus,  which  suggests  an  involvement  of  the  pons  by  pres- 
sure or  infiltration.  Stimulation  of  the  right  horizontal  canal  produced  a  normal 
nystagmus  and  marked  vertigo.  In  sj^ite  of  the  vertigo,  however,  the  left  arm 
failed  to  past-point  to  the  right. 


412  EQIILIBRIT  ]\I  AND  VERTIGO 

Tlie  salient  features  of  this  exainiiialioii   were: 

(1)  A  central  lesion. 

(2)  Destroyed  left  lalnrinlli  or  VIII  Nerve. 

(3)  Absenee  of  veifijro  and  past-pointing'  to  all  tests  exeei)t  doucliiiiii'  the 
riglit  ear  with  the  head  back — in  other  words,  the  only  past-pointing  that  was 
elicited  was  of  the  right  arm  to  the  riglit. 

A  central  lesion  with  a  loss  of  all  reactions  from  one  ear  indicated  that  the 
lesion  must  necessarily  involve  the  eerebello-[)ontile  angle  of  that  side.  The  al)- 
sence  of  vertigo  and  past-pointing  in  this  case,  howevei-,  was  so  marked  that  a 
cerebellar  lesion  had  to  be  considered.  The  following  report  was  made:  "The  ear 
examination  would  .suggest  a  large  lesion  of  the  cerebellum,  more  marked  on  the 
left  side,  pressing  into  the  left  cerebello-pontile  angle,  and  crowding  the  pons  to 
the  right,  aft^ecting  the  posterior  longitudinal  bundles  eithei-  by  infiltration  or 
pressure." 

Autopsy  on  May  2.5,  1915,  by  Dr.  Wohl  reads  as  follows:  ''A  mass  of  con- 
siderable size  was  found  anterior  to  the  cerebellum  on  the  left  side,  surrounding  the 
cranial  nerves  in  that  vicinity  and  particularly  adherent  to  the  VIII  Nerve  at  its 
point  of  emergence  from  the  temporal  bone.  This  mass  was  of  a  soft  consistency 
and  contained  four  small  cysts."     (Figs.  125  and  12().) 

Case  28.— Mrs.  Elizabeth  R.,  age  40.  Patient  was  referred  by  Dr.  F.  X. 
Dercum  on  April  25,  1915,  for  an  examination  of  the  vestibular  apparatus.  She 
gave  the  folloAving  history :  One  year  ago  she  began  to  be  troul)led  with  dizziness. 
Very  frequently  these  attacks  of  dizziness  would  assume  the  character  of  a  defi- 
nitely systematized  vertigo,  that  is,  objects  about  her  or  she  herself  would  actually 
appear  to  be  moving  in  one  oi-  the  other  direction.  Fight  months  ag'o  she  began 
to  stagger;  this  gradually  became  worse  so  that  now  she  cannot  walk  straight  at 
all.  Five  months  ago  vision  began  to  fail.  Thi'ee  months  ago  patient  suddeidy 
became  deaf  in  the  right  ear.  The  findings  of  tlie  ear  examination  are  given  in 
the  accompanying  chart  (XLI). 

Notes  of  her  physical  examination  were  not  available,  but  a  study  of  the  ear 
chart  alone  suggests  that  we  ai'e  dealing  with  a  central  lesion  because: 

(1)  Weakness  of  the  right  external  rectus  muscle. 

(2)  Tui'ning  to  the  left  i:>roduced  a  fair  past-pointing  of  the  right  arm  to  the 
left,  whereas  the  left  arm  did  not  past-point  at  all.  When  a  peripheral  lesion  inter- 
feres with  normal  i)ast-pointing  both  arms  are  usually  similarly  affected. 

(3)  Turning  the  j)atient  to  the  right  produced  a  past-pointing  of  the  right  arm 
to  the  left — in  the  wiong  direction.  A  peripheral  lesion  might  prevent  past- 
pointing,  but  is  not  likely  to  produce  the  wrong  kind  of  jiast-pointing. 

(4)  Douching  the  left  ear  produced  a  very  ])oor  nystagmus  from  the  vertical 
semicircular  canals  and  a  large  nj^stagmus  fi-om  the  horizontal  canal.  This  poor 
reaction  from  the  left  vertical  canals  could  hardly  be  accounted  for  by  a  lesion  of 
the  canals  themselves,  because  it  is  difficult  to  conceive  of  a  labyrinthine  disturb- 
ance which  would  markedly  affect  only  one  set  of  canals  and  leave  the  other  canal 
entirely  normal.     We  further  note  that   stinudation   of  the   right  ear  gave  abso- 


PATHOLOGIC  CASES  ANALYZED  413 

lately  no  responses.  This,  combined  with  total  deafness  on  that  side,  indicates  a 
destruction  of  the  light  labyrinth  or  right  VIII  Nerve — in  other  words,  a  peri- 
pheral lesion  of  the  right  side.  This  combination  of  a  central  and  peripheral  dis- 
turbance is  easily  explained  by  a  lesion  located  in  the  cerebello-pontile  angle. 

Two  days  later  another  ear  examination  was  made  and  the  findings  recorded  on 
the  acc()mi)anying  chart  (XLII).  It  will  be  noted  that  at  this  second  examination  the 
following  differences  were  observed: 

(1)  There  Avas  now  present  a  spontaneous  vertical  nystagmus  upward. 

(2)  At  this  time  there  was  a  distinct  weakness  of  all  the  ocular  muscles. 

(3)  Douching,  the  left  ear  with  the  head  in  the  "so-called"  upright  position, 
which  stimulates  the  left  vertical  semicircular  canals,  failed  to  produce  any  reac- 
tion. Evidently  something  had  occurred  in  the  past  two  days  which  interfered  with 
the  normal  responses  from  the  left  vertical  semicircular  canals  pathways. 

The  above  changes  simply  corroborated  our  opinion  that  we  were  dealing  with 
a  lesion  in  the  right  cerebello-pontile  angle.  An  increase  of  pressure  by  this 
lesion  could  well  accoinit  for  the  sudden  appearance  of  the  spontaneous  vertical 
nystagmus  upward,  the  increasing  weakness  of  the  ocular  muscles  as  well  as  for 
the  abolition  of  function  from  the  pathways  of  the  left  vertical  semicircular  canals. 

The  ear  repoi-t  was  as  follows:  "There  is  a  lesion  in  the  right  cerebello-pon- 
tile angle  (Fig.  127).  This  lesion,  however,  originates  i^robably  in  the  brain-stem 
and  involves  the  angle  secondarily  for  the  following  reasons: 

(1)  The  symptoms  in  this  case  date  as  far  back  as  one  year  ago,  whereas  the 
deafness  appeared  only  three  months  ago.  In  an  acoustic  tumor  deafness  would 
most  likely  be  among  the  first  symptoms. 

(2)  There  is  evidence  in  this  case  of  the  actual  involvement  of  the  posterior 
longitudinal  bundles  themselves,  because  the  HI  and  VI  cranial  nerves  are  eon- 
sidei-ably  involved,  and  there  is  jiresent  a  spontaneous  nystagmus  in  every  direction. 

(3)  There  is  an  inco-ordination  of  associated  ocular  movements.  When  the 
left  horizontal  canal  was  stimulated  tlie  resulting  nystagmus  was  different  in  each 
eye;  the  left  eye  showed  a  larger  excursion  than  the  right." 

The  patient  was  operated  on  by  Dr.  J.  C.  D'aCosta  and  the  right  cerebello- 
pontile  angle  exposed.     A  large  tumor  was  found  which  it  was  impossible  to  remove. 

Two  weeks  later  when  the  patient  had  sufficiently  recovered  from  the  opera- 
tion, another  examination  of  the  vestibular  apparatus  was  made  and  some  very 
interesting  changes  noted. 

(1)  Signs  of  improved  function:  (a)  Spontaneous  ocular  movements  are  less 
restricted;  {b)  Stimulation  of  the  left  vertical  semicircular  canals  fibres  now  again 
produces  responses;  (c)  On  looking  upward  there  is  a  less  noticeable  vertical 
nystagmus  upward,  and  it  has  assumed  a  more  rotary  character. 

(2)  Sign.s  of  further  impairment:  (a)  There  is  now  a  marked  inco-ordination 
of  the  right  arm;  {b)  The  left  arm  does  not  point  to  the  left  when  the  left  ear  is 
douched  in  spite  of  a  good  nystagmus.  This  would  suggest  an  extension  of  the 
lesion  either  into  the  cerebellum  itself  or  an  involvement  of  the  nerve  fibres  on  their 
way  to  or  fi-om  the  cerebellum. 


414  EQUILIBRIUM  AND  VERTIGO 


CHART  XLI  A 

Name  -//a^  (£ L^<Jxxl  /(■  ^^^   ^O  D^te  JdyuJi  J^S;  ICj  /S. 

Addrfcss  "  ^-^  o/"  "^  r  ' 

Referred  l.y   ^Jrr  ^     -<■    x3 e-i-e>-^^-c.  ■ 


DIAGNOSIS: 


SUMJMARY: 


Complains  of    ^jL.cL^^.ui^i^ ,  V-iyCCl^a- ^    (^Zo^jAA-<'<^- 


HISTORY: 

Dizziness  -/tvc^^jjloU-  .eXCHjiA^  ,ti*,LAA..-j^^  J""^   y^*^ 
Staggering  Yi^^    f  ry^^r^O^  ^-^ ,- ^    w.X-'  - 


Deafness  cUfX^   ^   ..^   QJr .    fi.^  _    J  ;_i^    ^. 
Tmnitus  J}^,^  /  / 


NOSE:       <^^a;>^    jl^cx.^^^.*^ 
THROAT:       Jh^ 


EARS: 


Fistula    jyj.    X^TL«t 
Hearing  Tests 


lests  ^ 

A|°  A|o  Ar      ?       Re      .^  n  Pol.  |  -  cMo  Gait  I  -         -^^^/^ 

Z  ir  A.:      >       Be      <  n  I  \^,^  \  ti  C^f 

ofta^t-      jL^^aU'    /U^-<-^     --i-»-r'- 


Ck^ 


PATHOLOGIC  CASES  ANALYZED 


415 


CH.\RT  XLI  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 

Looking  to  RIGHT  "^ — -    i«jLji^-\       Shoulder  from  above 

Looking  to  LEFT  — >  >>-^  vxrx.^]*^ 

Nystagmus  ^  •d/f^-  »^  £>-.^^-^^    %   ^^^ 
Looking  UP    Jl-(ruje^  Vertigo    Arv^  ^ 

Past-pointing  -jj-zn^jt. 
Looking  DOWN   J}-cn^X^  Falling  ^,,->.^ 

Romberg    ■^jt'f  c-Zw-C 

Turning  head  to  right  cJ^mAJ-  iu.>^^. 
^ju^aoitCr^  /7.  M-i.AA^uy.^14^  Turning  head  to  left  " 

^  {i^  t^-aZ^  A<,a::<.  .  ^''^^^l  to  overthrow  Oil^^  ^  «  ^ 


POINTING 


RIGHT 


LEFT 


■h^U^A^L^ 


To  RIGHT  - — ^ 
Duration  /<>  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


To  LEFT   <r 


Amp.  ,Cuca.i. 
1 


Nystagmus   J^^oaA^^ 
Vertigo    J^^rujt 
Past-pointing     yr-r^'^ 


To  LEFT 
Shoulder  from  above 


^^''to/j^ 


Nystagmus  Ji  yuJioAn^^ 

Vertigo  ^,iA*M.*L^ 

Past-pointing  J) iAA.()ouiM-J^  A^-jaiJ-,   oJ^^-'^^^yi  ^^■"'4^  -tj^i-t/^. 


(^uiuU^t^ 


Douche  RIGHT    J■^r^-^JU 

Amp.    Jf-irvJL^ 

After  ^  min.        sec. 


Head  Back    Ajtv^.^ 
Amp. 


CALORIC 


Douche  RIGHT 

Shoulder  from  above 


^jZJLul     (^T^Zucl^^ 


Nystagmus   ^r- 
Vertigo    ^. 
Past-pointing    ^' 
Falling    J^t 


Douche  LEFT 
Amp.  y^- 


m 


After    /   min.  g"  sec. 


Douche  LEFT 
Shoulder  from  above 


J'-to^.^ 


Nystagmus  rXw«^a/t>4/t-^ 
Vertigo  ,/^>/u«-a^ 
Past-pointing     Jjr.o^i''''^ 
Falling      Jhjy'u>'-a£r  . 


3"to^- 


Head  Back 


Amp.  Co 


<.^ 


^"to/^l  3"to/(i^. 


41G 


EQUILIBRIUM  AND  VERTIGO 


CHART  XLll 


NYSTAGMUS 
Looking  to  RIGHT  < 
Looking  to  LEFT  


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


POINTING 


.   yy^'OiAJ^J^ 


RIGHT 
Shoulder  from  above   v~i-i<.j   i-tt^to-i'x.^^^^t-^i-^i-     l-^ 


x>^t/i-c^-^*^»-*- 


,,j^. — ^„.^y   „  ^v-7~—  Nystagmus  x^  f^i,-i^  xrOy<y(-^U-<^r^  x^'^'^^J- 

Looking  UP  ^O  -a-^     '  Vertigo    Jl'-'rv^ 

Past-pointing  j\'*^'^C^^*^Civ    Jvo-n.^^ 
Looking  DOWN  Jh^n^  Falling    ^...^  ' 

Romberg     (f/^'h/J-  L^-fi^j^^a 
Turning  head  to  right  .viwvd'  , 
Qi/i^i,^^  4<^  ^^v<^5U.  *,«-^       Turning  head  to  left  -  .,    . 

/  Attempt  to  overthrow  •/\jL>->^   <x/t,^^ 


-  J^^-^^L*.*^^    .atc^ftru^ 


LEFT 


To  RIGHT    — =3- 
Amp.  j-a-iA^ 
Duration   lo  Sec. 


To  LEFT    -^^ 

Amp.  •C«^<^ 
Duration    /t>  Sec. 


TURNING 

To  RIGHT 

Shoulder  from  above 

Nystagmus    e^'^"^-^^^^^^^ 
Vertigo   ^«-w<-. 
Past-pointing    ,A;,r<.^Ji^ 


To  LEFT  I 

Shoulder  from  above  .^*  to/t^ 

Nystagmus    Jc-^yOZiu^ 

Vertigo  jJ'tf'uM-oJL  i    -r    P  J 

Past-pointing    *^  ^^  'O^'^  .aJ^'^cO.    ^  C^ 


<^W^A^ 


Douche  RIGHT   ^^"v^ 
Amp. 
After  3    min.        sec. 


Head  Back 

Amp. 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 


Nystagmus  ^r\^jt^ 
Vertigo     A-.b~„.jl. 
Past-pointing    ^t-i-dL. 
Falling     J^tr^-ui^ 


J-6 


Jh 


Douche  LEFT 
Amp. 
After   3    min.  .^^^sec. 


Head  Back 


Douche  LEFT 
Shoulder  from  above 

Nystagmus  ^f^ru-t. 
Vertigo  o/>>>^ 
Past-pointing    •yrjrTAji- 
Falling    Jh^,-,^^ 


Amp.  <(« 


■"7^ 


^^    <y^  .>...«.<^  ^r^  ^s^-^  ^  ^^" 


£-■■  to  /^ 


PATHOLOGIC  CASES  ANALYZED 


417 


Comment 

Clinical  experience  with  cerebello-pontile  angle  lesions  has  fre- 
quently shown  that  the  vertical  semicircular  canals  of  the  side 


RIGHT 


LEFT 


,,/TEMPORAL 
LOBE 


Fig.    127. — Large  tumor  in  right  cerebello-pontile  angle. 


opposite  the  lesion  fail  to  respond  to  stimulation.     This  has  oc- 
curred with  such  a  uniformity  that  no  phenomenon-complex  ap- 


418  EQUILIBRIUM  AND  VERTIGO 

pears  to  De  complete  without  it.  We  had  always  supposed  that  it 
was  due  to  pressure  transmitted  across  the  midline.  This  case 
demonstrates  the  truth  of  this  assumption.  The  left  vertical  semi- 
circular canals  and  pathways  responded  to  stimulation  on  the  first 
examination ;  two  days  later  they  failed  to  respond.  After  the 
decompression  operation  was  done  we  were  again  able  to  obtain 
responses,  which  proves  that  there  was  no  organic  involvement 
of  the  fibres,  but  that  they  were  simply  affected  by  the  increased 
pressure. 


Case  29. — Miss  Anna  S..  age  33.  Patient  was  admitted  to  the  University  Hos- 
pital on  June  2,  1916.  with  tlie  chief  complaint  of  "staggering"  and  '"blind  spells." 

The  trouble  commenced  three  years  prior  to  her  admission  to  the  hospital. 
The  first  thing  she  noticed  was  that  she  would  become  dizzy  while  dancing.  Shortly 
after  that  she  would  become  dizzy  evei-y  time  she  turned  her  head  to  the  right.  A 
little  later  it  was  noticed  that  she  could  not  walk  in  a  straight  line.  The  vertiginous 
attacks  were  associated  with  tinnitus.  Examination  at  that  time  disclosed  a  right- 
sided  deafness.  She  went  along  in  fair  comfort  until  about  three  months  ago, 
when  the  "blind  spells"  became  much  more  pronounced;  they  would  come  on  more 
frecjuenrty  and  would  last  a  longer  period  of  time.  The  hearing  becomes  very 
much  worse  during  those  blind  spells.  At  no  time  did  she  have  headache  or 
vomiting. 

The  previous  medical  history  as  well  as  the  family  history  is  negative. 

The  following  is  a  report  of  the  physical  examination :  "Patient  is  an  adult 
female  of  small  stature.  The  right  side  of  the  face  seems  to  be  slightly  weaker. 
The  patient  is  unable  to  lift  the  right  corner  of  the  mouth  as  well  as  the  left. 
Patient  is  able  to  distinguish  between  "shaii^"  and  "dull"  over  the  right  side,  but 
the  point  of  the  pin  does  not  feel  as  sharp  on  this  side  as  it  doe^  on  the  left. 
When  Avalking  with  the  ej'es  closed  she  staggers  slightly  to  the  left — this  is  not 
marked.  There  is  no  ataxia;  there  is  no  weakness  of  the  limbs;  no  Romberg;  no 
ankle  clonus;  no  Babinski ;  the  knee  jerks  are  sliglitly  weak.  Examination  of  chest 
and  abdomen  negative." 

Eye  Examination  hi/  Dr.  Sliumivai/. — Low  grades  of  optic  neuritis  in  both 
eyes.  Height  of  the  nerve  is  not  over  3  diopters.  Vision  in  the  right  eye.  G/l'2ths; 
in  the  left,  6/30ths.  There  is  a  concentric  contraction  of  both  fields,  especially  the 
left.  Pupils  react  to  light  and  accommodation.  Extraocular  muscles  seem  normal. 
There  is  a  constant  rotary  nystagmus  to  the  left,  much  iiu^'eased  by  looking  to  the 
right  or  left. 

X-ray  examination  negative. 

The  patient  was  under  the  care  of  a  neurologist,  who  sent  her  to  the  Uni- 
versity Hospital   with  the  folloAving  report :   "The   histoi'y  and   the   present    con- 


PATHOLOGIC  CASES  ANALYZED  419 

dition  all  point  to  a  cerebellar  involvement.  The  involvement  of  the  V  and  VIII 
Nerves  of  the  right  side  speak  in  favor  of  a  probable  neoplasm  in  the  right  cere- 
bello-jioutile  angle.  In  view  of  the  gradnal  loss  of  vision  we  advised  a  snbtem- 
poral  decompression  operation." 

An  examination  of  the  vestibular  apparatus  was  made  on  June  2,  1916,  and 
the  tindings  recorded  in  the  accompanying  chart  (XLIII). 

The  hearing-  tests  demonstrated  normal  hearing  on  the  left  side  and  total 
nerve-deafness  on  the  right  side. 

Without  reference  to  the  neurologic  aspect  of  the  case,  the  result  of  the  ear 
examination  would  seem  to  suggest  at  first  glance  a  labja-inthine  lesion.  The 
gradual  onset  of  the  deafness,  for  it  nuist  be  recalled  that  it  was  noted  as  long  as 
three  years  prior  to  this  examination,  the  tinnitus  which  was  always  more  marked 
during'  the  "blind  spells,"  the  presence  of  a  sjaontaneous  rotary  nystagmus  which 
usually  accompanies  labyrinthine  disturbances — all  these  would  suggest  a  peri- 
pheral lesion.  Furthermore,  the  shortened  duration  of  the  nystagmus  after  turning 
to  the  left  would  api^ear  to  bear  out  the  theory  of  a  destroyed  right  labyrinth.  A 
careful  study  of  the  chart  alone,  however,  would  show  that  w'e  are  dealing  with  a 
central  lesion  because : 

(1)  The  spontaneous  eye  movements  were  not  the  same  in  both  eyes.  The 
nystagmic  movements  in  the  light  eye  were  more  marked  than  in  the  left.  This 
obviouslj"  could  never  be  produced  by  a  labyrinthine  lesion. 

(2)  Turning  to  the  right  produced  a  good  horizontal  nystagmus,  in  the  proper 
direction,  of  2-1  seconds.  This  of  itself  would  indicate  the  ability  of  the  "end- 
organ"  to  generate  normal  impulses.  We  should  thei'efore  expect  normal  past- 
pointing.  Instead  of  this  the  left  arm  failed  to  past-point  to  the  right.  Similarly, 
turning  to  the  left  failed  to  produce  normal  past-pointing  of  the  right  arm  to  the 
left — in  other  words,  the  past-pointing  with  both  arms  is  outward,  no  matter  what 
the  direction  of  the  turning.  Such  "crossed"  past-pointing  is  explicable  only  on 
the  basis  of  a  central  lesion. 

(3)  Douching  the  left  ear  with  cold  water  produced  a  perverted  nystagmus, 
Avhicli  indicates  a  brain-stem  disturbance. 

A  salient  feature  of  this  examination,  however,  is  the  total  absence  of  all  re- 
sponses from  the  right  side,  which  indicates  a  peripheral  destruction  of  the  right 
ear  or  all  of  its  pathways.  For  a  central  lesion  to  involve  the  peripheral  ear 
pathv/ays  it  must  be  situated  in  the  cerebello-pontile  angle,  where  the  VIII  Nerve 
enters  the  brain-stem. 

The  following  report  was  made :  "A  lesion  of  the  right  cerebello-pontile  angle 
involving  the  cerebellar  substance  and  probably  inoperable." 

The  patient  was  operated  on  on  June  17,  1916,  and  a  lai'ge  mass  found  in 
the  right  cerebello-pontile  angle  which  it  was  impossible  to  remove. 

The  autopsy  showed  that  anterior  to  the  right  cerebellar  region  there  was  an 
egg-shaped  mass  measuring  5  by  iVs  by  3  cm.  It  was  of  the  same  color  as  the 
rest  of  the  brain,  of  rather  firm  consistency,  definitely  encai)sulated  and  appar- 
ently not  attached  to  the  cerebellum.  The  right  cerebellar  lobe  itself  had  lost  most 
of  its  characteristics.  It  was  rather  soft,  somewhat  cystic  with  indistinct  striations. 
The  microscope  showed  the  specimen  to  be  a  glioma.     The  hypophysis  was  normal. 


420  EQUILIBRIUM  AND  VERTIGO 


CHART  XLIII  A 


Name    ./^M-^^  ^v<,«-a,  CV.  Age  >?5  Date   i/>'^''^^  ^.    'f'(c 

Address  n  / 

Referred  by     ^^<^-n/-t/u«lZy    ^-l^-iJixZ^X. 


DIAGNOSIS: 


SUMMARY: 


Complains  of    J fy^^'^^'-<-«^    .^«^      it-^l^    t>^<M^. 


HISTORY:  . 

Dizziness  ^^-i^ay 
Staggering  ^^^^ 
Deafness  i^,^^^^ 
Tinnitus       }j,f_^ 


NOSE:         •At^iXZi, 


THROAT:    ^j^,JZ^- 


7' 

r 

EARS:  .  .^ 

A.  S.  &  Ji^ixlly  /rClZn^Xjt^  ,  »Z<^'a/LA    a>t.cu^    0-'ut:'*i'  -^  tt-nc^^o  . 

Fistula     J-^f  /C*^2^ 


Headng  Tests  , 

A]o  Ajo  Aco       Be     On  Pol.  L<^  cM  "  Gait  1  •  "» 

""li/i  If  Ac    >      Be    <      n  I  l4£o-e^  I 


PATHOLOGIC  CASES  ANALYZED 


421 


CHART  XLIII  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


m'STAGMUS 
Looking  to  RIGHT .   ^^ 
Looking  to  LEFT    /^ 
Looking  UP     ^^ 
Looking  DOWN    ^*i<-<^ 


POINTING 


RIGHT 


1       Shoulder  from  above 

Nystagmus  J^^to^  ^  •C^ 
Vertigo  ^,*vix. 
Past-pointing    yA-in^oL. 
Falling  ^«T„t^ 

Romberg    ./^    .t<->«-»rxx*^  . 

Turning  head  to  rigltt     -o^c^t-e^  .<.^   A^-t-iU^t^  /<Ujk>-tnx4. 

Turning  head  to  left  "  •■  .,  /_ 

Attempt  to  overthrow  ,^iZ,»<,</  yaj^ZeCyCe  AtjucZi,    H-*-t.<— -«U^</ 


LEFT 


To  RIGHT     > 

Amp.    -JtMvt^ 
Duration  AylSec. 

To  LEFT  < — 
Amp.  ■0>A^ 
Duration  /j  Sec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    ^L»-t-^ 
Vertigo    djU'aJil 
Past-pointing  >(^ 


^dA.***-      ^t-tA^ 


To  LEFT 
Shoulder  from  above 


^w-t^t*^ 


Nystagmus  <« 


*^^, 


iw^  fJit^dZt-U^  . 


cT"  to^ 


Vertigo  iu<^  ■  «„«^i»»o«^ 

Past-pointing  J^iUJ-  oa^m.  <nriStZ,iuui*-  ^  i^^  -  -^.^-x^ 


""'f^. 


fC. 


Douche  RIGHT  -^'■ 
Amp. 
After  J    min 


Head  Back  ^ 
Amp. 

"Douche  LEFT  lO  '>^"-<-  ■ 
_  Amp.  ^^^j<. 
After         niin.  ^<5sec. 


Head  Back   / 
Amp-        Id,,^ 


^^./Urv-f    ,eLAA,<JZn^    tflJU  /^iM.   f^XL^.**^  fm-  /f  tr  /(,  tvyJAX^UJOrl- 


CALORIC 


Douche  RIGHT 
Shoulder  from  above 


,)£/■     '^^^leA^ 


Nystagmus  -^-"t*^ 
Vertigo  ,A'trvu^ 
Past-pointing    ..//i 
Falling  ^^.r,^ 


Douche  LEFT 
Shoulder  from  above 


/ 


Nystagmus     J-c^*-/.    U^    JSjtyiy<^<A^Gi^- 

Vertigo  v^<n-t^ 

Past-pointing 7?'a^  ao*^    iv'Urv^  ji.iAAxZ^^^i^  . 

Falling  J^^  / 


P,/ 


/^"to  /^ 


cji^:ju   Q^:::citjL 


Ji-tq^^    ^"to/^*^ 


/"I 


oAJ*' 


/r 


4  2  "2 


EQUILIBRIUM  AND  VERTIGO 


Comment 

The  neurologic  data  in  this  case  was  sufficient  on  which  to  base 
a  diagnosis  of  tumor  in  the  right  cerebello-pontile  angle  (Fig.  128). 


RIGHT 


LEFT 


Fig.   12S. — Tumor  in  right  cerebello  pontile  angle. 


The  ear-examinati(ni,  however,  was  useful  not  merely  in  corrobo- 
rating the  neurologic  diagnosis,  but  also  in  furnishing  additional 
information  as  to  the  extent  of  the  lesion.  It  will  be  noted  that 
under  no  conditions  were  we  able  to  produce  a  past-pointing  of  the 


PATHOLOGIC  CASES  ANALYZED  423 

right  arm  to  the  left  no  matter  what  type  of  stimulation  was  em- 
ployed. This  suggested  an  actual  involvement  of  the  right  cere- 
bellar hemisphere.  Stimulation  of  the  left  vertical  semicircular 
canals  produced  practically  no  responses.  This  of  itself  would 
suggest  an  involvement  of  the  left  side  of  the  pons.  This  involve- 
ment, however,  was  one  jDroduced  by  pressure  rather  than  in- 
filtration, because  turning  the  patient  both  to  right  and  to  left  with 
the  head  forward  (in  which  position  the  vertical  semicircular 
canals  were  stimulated)  produced  a  good  rotary  nystagmus  with 
falling,  which  distinctly  demonstrated  that  the  vertical  canals 
pathways  were  not  destroyed.  Douching  produced  no  responses 
because  the  caloric  type  of  stimulation  is  much  weaker.  The 
autopsy  corroborated  the  findings  of  the  ear-examination. 

Case  30. — John  B.  Iv.,  age  39.  Patient  had  been  in  perfect  health  until  the 
sirring  of  1914,  when  he  began  to  have  occasional  headaches.  In  September,  1914, 
as  he  was  stejiping  off  of  a  train,  he  was  suddenly  seized  with  violent  vertigo, 
nausea  and  vomiting.  The  vertigo  was  so  severe  that  he  fell  to  the  platform  and 
was  taken  to  the  hospital,  where  he  was  confined  to  bed  for  ten  days,  during  which 
time  the  vertigo  gradually  diminished.  At  the  time  of  this  attack  of  vertigo  there 
was  coincident  complete  deafness  in  the  right  ear.  For  the  next  two  months  his 
symptoms  gradually  improved  and  he  was  disturbed  only  by  occasional  staggering. 

A  careful  neurologic  examination  in  December,  1914,  that  is,  three  months 
later,  failed  to  reveal  any  cause  for  staggering. 

Ear  examination,  made  at  this  time,  showed  complete  destruction  of  the  right 
cochlea  and  no  resjjonses  whatsoever  from  any  of  the  semicircular  canals  of  the 
right  ear.  The  Wassermann  test  was  made  at  two  different  laboratories  and  from 
each  laboratory  came  the  report  of  a  4-|-  Wassermann.  It  was  obviously  from 
the  ear  tests  that  either  the  right  labyrinth  or  VIII  Nerve  was  destroyed.  The 
diagnosis  suggested,  therefore,  was  a  specific  neuritis  or  labyrinthitis  of  the  right 
side. 

This  diagnosis,  however,  was  absolutely  incorrect.  There  was  noted,  even  on 
this  first  examination,  a  spontaneous  vertical  nystagmias  upwards,  and,  in  fact, 
moving  pictures  were  taken  of  this  nystagmus  at  the  time. 

Subsequent  history  of  the  case  showed  how  badly  we  eiTed  in  not  realizing 
fully  the  significance  of  spontaneous  vertical  nystagmus.  As  time  went  on  his 
vertigo  increased  and  the  headache  became  worse.  In  December,  that  is,  three 
months  later,  he  noticed  that  his  vision  was  failing  and  his  loss  of  vision  was  be- 
coming progressively  worse.  In  April  of  the  following  year  he  began  to  cough. 
There  was  no  pain  in  his  chest  and  no  expectoration,  but  this  has  gradually  de- 
veloped into  hoarseness.  He  was  losing  weight  and  getting  generally  weak,  so 
that  in  April  of  1915  he  applied  for  admission  to  the  University  Hospital. 


424  P:QI  ILIBRIUM  AND  VERTIGO 

The  following  notes  of  the  jjhysical  examination  at  the  hospital  were  made: 
"There  is  a  marked  impairment  of  the  right  apex  with  prolonged  and  harsh 
breath  sonnds.  Few  fine  inspiratoi*y  rales.  Tactile  fremitus  increased  here.  The 
rest  of  the  lung  is  normal.    Heart  and  abdomen  negative. 

"Eyes,  slight  exophthalmus.  Pupils  c(iual,  react  to  light  and  distance.  There 
is  no  nystagnnus  on  looking  straight  ahead,  but  there  is  a  lateral  nystagnuis  on 
looking  to  either  side.  This  is  more  marked  when  he  looks  to  the  right.  There 
is  a  vertical  nystagmus  on  looking  upward.  Paresis  of  the  right  extei'nal  rectus. 
Both  eye-grounds  show  choked  disc — -i  diopters  in  the  right  and  5  diopters  in  the 
left.  There  is  a  marked  retinal  oedema  with  a  great  amount  of  exudate  and  with 
numbers  of  retinal  hemorrhages.  The  choking  has  evidently  been  present  for 
some  months.     A  rough  test  of  the  visual  lield  shows  no  decided  limitation. 

"Nose  and  throat.  Pharynx  slightly  congested.  There  is  slight  difficulty  in 
swallowing.  Large  perforation  of  cartilaginous  nasal  septum.  Loss  of  sensation 
of  the  right  half  of  the  soft  palate.  Left  vocal  cord  moves  easily,  the  right  cord 
is  stationary. 

"No  disturbance  of  sensation  in  the  face.  Adiadokokinesis  in  both  hands,  but 
far  more  marked  in  the  right.  Slight  weakness  of  grip  in  the  right  hand.  Sense 
of  position  in  both  arms  normal.  Sensation  present  on  both  sides.  In  finger-to- 
nose  test  there  is  slight  ataxia  on  both  sides.  Reflexes  exaggerated  on  both  sides. 
Both  knee  jerks  exaggerated.  Babinski  present  on  left,  doubtful  on  right.  No 
ankle  clonus.  On  standing  patient  falls  to  left.  When  walking  staggers  to  both 
sides,  but  especially  to  the  left." 

Wassermann  reaction  negative.     X-ray  examination  negative. 

Sputum  examination  negative. 

Blood   count  practically  normal  except  that  there  are  15,000   leucocytes. 

Patient  was  oi^erated  on  by  Dr.  Frazier,  April  22,  1915.  Bilateral  cere- 
bellar decompression.  After  the  dura  was  opened,  the  right  hemisphere  bulged 
perceptibly,  much  more  than  the  left.  At  this  stage  of  the  operation  it  was 
thought  wisest  to  discontinue  further  exploration,  until  the  sti'uctures  could  ac- 
commodate themselves  to  the  relief  of  tension. 

The  patient  later  died  and  at  autopsy  a  large  cyst  was  found  which  appar- 
ently originated  in  the  right  cei-ebello-pontile  angle  and  invaded  the  right  cere- 
bellar hemisphere.  There  was  marked  pressure  against  the  brain-stem,  which  was 
displaced  to  the  left. 


Comment 

The  diagnosis  of  specific  labyrinthitis  or  specific  involvement 
of  the  right  VIII  Nerve,  made  on  the  original  ear-examination, 
was  not  onl}^  unfortunate  but  entirely  unnecessary.  The  strongly 
positive  Wassermann  reaction  apparently  gave  a  clue  to  the  orig- 
inal source  of  his  trouble;  subsequent  Wassermann  tests  were  en- 


PATHOLOGIC  CASES  ANALYZED  425 

tirely  negative.  As  we  look  back  on  this  case,  however,  we  realize 
that  it  was  not  so  much  the  lack  of  information  at  the  time  of  the 
original  examination,  but  our  wrong  interpretation  of  the  findings 
which  led  to  this  incorrect  diagnosis.  Although  the  history  of  the 
onset  of  his  original  attack  pointed  to  the  diagnosis  of  a  sudden 
destruction  of  the  right  labyrinth — as  he  gave  the  typical  classical 
picture  of  the  so-called  ''Meniere's  disease,"  yet  there  were  cer- 
tain facts  which  could  not  have  been  explained  on  the  basis  of  such 
a  diagnosis : 

(1)  The  spontaneous  vertical  nystagmus  botli  upward  and 
downward.  Since  the  time  of  this  examination  we  have  come  to 
learn  that  such  a  nystagmus  cannot  be  caused  by  an  involvement 
of  either  the  labyrinth  or  VIII  Nerve  and  that  it  is  pathognomonic 
of  an  intracranial  lesion  and  indicates  an  involvement  of  the  brain- 
stem either  by  infiltration  or  pressure. 

(2)  The  patient  had  noticed  a  distinct  diplopia  for  a  full  day 
following  the  original  attack. 

These  two  findings  should  have  put  us  upon  the  right  track 
and  made  us  realize  that  we  were  not  dealing  with  an  end-organ 
lesion. 

Case  31.— Mr.  W.  H.,  age  48.  Patient  was  admitted  to  the  University  Hos- 
pital on  Januarj'  26,  1910,  with  the  chief  complaint  of  headache,  vertigo  and  stag- 
gering. He  gave  the  following  history:  Three  months  before  admission  to  the 
hospital  he  bumped  his  forehead.  This  was  followed  by  dizziness,  which  rendered 
him  unable  to  work.  Headache  came  on  a  week  later.  These  are  constant,  are 
chiefly  frontal,  but  also  extend  to  the  top  of  the  head  and  occiput.  Although  he 
had  been  hard  of  hearing  for  15  years  in  the  right  ear,  this  has  become  a  great  deal 
worse  since  the  onset  of  the  trouble.  Two  months  before  admission  he  began  to 
stagger,  mainly  to  the  left,  but  now  he  thinks  that  he  staggers  to  the  right  instead. 
He  noticed  at  this  time  that  his  vision  was  becoming  poorer.  He  has  some  diffi- 
culty in  swallowing  liquids  and  he  thinks  that  his  voice  is  not  what  it  ought  to  be. 

The  previous  medical  history,  social  and  family  history  are  negative. 

He  denies  venereal  history. 

The  chest,  heart  and  lungs  are  normal. 

The  sense  of  smell  is  unimpaired.  Sensation  to  pain  and  touch  is  normal 
over  the  face,  trunk  and  extremities.  The  reflexes  are  slightly  increased  in  both 
upper  and  lower  extremities. 

A  lumbar  puncture  revealed  a  normal  cerebro-spinal  fluid. 

The  Wassermann  is  negative. 


426  EQUILIBRIUM  AND  VERTIGO 


CHART  XLIV  A 


Name 

Address 


j{.    ^'^  Age   ^<r  Date  '^    '■   'P^ 

ess  ^    ,  o/      / --t-  ff 

Referred  by     ,%^-'-^>iA^^  c^f^-<L^-J^^ 


DIAGNOSIS: 


SUMMARYT 


Complains  of    "i^AtX^^  ^.a^^^   eto-^^A/^-^..-^  . 


//         /' 


HISTORY:  . 

Dizziness     -J^^^^ 
Staggering    XJl^i/ 
Deafness      4^^<-4/ 
Tinnitus       ^'t^y 


NOSE: 
THROAT 


A.  D.    ^j^xJOU^ 


E.\RS: 

A.  S.     JrM}cJ-^^<' 


Fistula     •Jf^o^^^ 

Hearing  Tests  /{/cAc^ 

A  I  o  A  I  °  Ac  Be     •        n  Pol.  \-^-y^^  c«  I  °  Gait  1  » 

~l;2  I  ?  Ac    >      Bo    =     n  Wy-a:^      Y^"^  \/.s  ^^ 


PATHOLOGIC  CASES  ANALYZED 


427 


CHART  XLIV  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGMUS 

Looking  to  RIGHT    < 

Looking  to  LEFT    — > 
Looking  UP     f 
Looking  DOWN   ^ 


POINTING 


Shoulder  from  above 


RIGHT 


■cUf.    eL^k/f^eiif 


Nystagmus    //i-»'«-<-^ 

Vertigo     U-i^ 

Past-pointing    /?  o-v<-«' 

Falling     yZ^y    J^  R^^JJ- 

Romberg   <2<rvcA*itM./>X&--  /«u*A«Ljyt*/tUf 

Turning  head  to  right  -do^A^  .-«.^-  .tJLLc^  "Z^-t- 

Tuming  head  to  left 


(J      <7 


Attempt  to  overthrow  A^dLx^  ^-ca«££«    .Ut^a^  *<-^-  ^rt. 


LEFT 


.  ZJkA^      'Cl^     &^&tf 


To  RIGHT   — :5»> 
Amp.  ^^^^ 
Duration  /5"Sec. 


To  LEFT    < 

Amp.  y^uc/f 
Duration   5.aSec. 


TURNING 


To  RIGHT 

Shoulder  from  above 


Nystagmus    Jaa^^o^j^-'^ 
Vertigo  -" '■^^o^^^^'^ 
Past-pointing  OM^j^^  '^ 


/6o-c*jCl**.<y    "y^ 


To  LEFT 

Shoulder  from  above 


Nystagmus   J'-^^a^y^^'i^ 

Vertigo   Ji  .^^O'^^aaJL 

Past-pointing  CUmA^~,trJIL,-^,rel-  jLo->yJZ<4^ 


3"    *o^ 
S  "to  /f^ 


^■■loT^jdc- 


/ittfjUcAlL^ 


CALORIC 

Douche  RIGHT    -^^--^ 
Amp.  .>f<rv«*- 
After  Q  min.  ao  sec. 

Nyst 
Verti 
Past- 

Douche  RIGHT 
Shoulder  from  above 

IgmUS       ./TcrT-^- 
go     A\iT-v~JL 

pointing    tA-^^-uut. 

({/^Z<:^^ 

Jb<i,u>-£pJ. 

Head  Back    Jl-^rv^ 
Amp. 

Falhng    Jhcr^c^ 

^<n*«/^ 

%;zd^ 

Douche  LEFT     ^ 

Amp.  2^I3U- 

After    /    min.  /o  sec. 

Head  Back    .^ 

Amp.   ^oir^ 

Nyst 
Verti 
Past- 
Fallii 

Douche  LEFT 
Shoulder  from  above 

igmus     -^^►'U-"*^ 
pointing    jy^.^.^^,^ 

^-lo-C'^ 
^■'  to^^ 

428  EQUILIBRIUM  AND  VERTIGO 

Eye  Ejamiiiatioii  by  Dr.  Shumicay. — Pupils  equal  and  resj^ond  iironiittly. 
Ocular  movements  restricted.     Eye  grounds  entirely  healthy. 

Dr.  Charles  K.  Mills  dictated  the  following  notes:  ''There  is  a  marked  Rom- 
berg both  with  the  eyes  open  and  shut.  He  can  scarcely  stand  Avithout  support. 
Staggers  to  the  right  in  an  awkward  effort  to  walk.  There  is  present  a  marked 
nystagmus  in  every  direction  in  which  he  attempts  to  look.  The  right  palpebral 
fissure  is  wider  than  the  left.  The  horizontal  wrinkles  of  his  forehead  are  some- 
what more  extended  to  the  left  side  and  he  does  not  draw  up  the  right  angle  of  the 
mouth  as  strongly  as  the  left.  In  attempting  to  whistle  or  to  blow  with  his 
mouth,  the  oral  movements  are  more  positive  on  the  left  side.  Patient  has  a  very 
distinct  dysarthria.  The  speech  is  what  might  be  termed  a  bulbar,  paretic  kind. 
He  also  has  direct  dititieulty  in  swallowing.  When  he  attempts  to  drink  water  it 
goes  down  with  difficulty  and  regurgitates  slightly.  The  soft  palate  moves  scarcely 
at  all.  With  it  there  is  an  anesthesia  of  the  soft  palate  and  pharynx,  which  is 
bilateral  just  the  same  as  the  palsy.  The  voice  is  distinctly  nasal.  The  patient 
shows  distinct  adiadokokinesis.  particularly  in  the  right  upper  extremity.  There  is 
dysmetria  in  the  finger-to-nose  test  which  is  very  marked  in  the  right  and  shows 
itself  as  an  undershooting  (hj'pometria)." 

An  examination  of  the  vestibular  apparatus  was  made  on  February  1,  1915, 
and  the  data  obtained  shown  on  chart  XLIV. 

It  wiU  be  noted  that  the  hearing  is  good  on  the  left  side  and  totally  gone  on 
the  right. 

There  is  a  spontaneous  nystagmus  in  eveiy  direction  but  more  marked  upward 
and  downward.  The  pelvic  girdle  reactions  are  veiy  poor — the  patient  falls  over 
like  a  broomstick  at  the  slightest  touch. 

Turning  produces  an  impaired  nystagmus  and  what  may  be  termed  '"ci-ossed'' 
past-i^ointing.  Turning  to  the  right  and  turning  to  the  left  always  produces  a 
past-pointing  of  both  anns  inward — in  other  words,  there  is  always  an  absence  of 
the  outward  past-pointing  of  both  anns  after  turning. 

The  calorie  test  shoAvs  a  dead,  non-responsive  ear  on  the  right  side  and  normal 
responses  on  the  left. 

The  presence  of  a  vertical  nystagnnus.  a  stiff  pelvic  girdle  and  the  peculiar 
past-pointing  after  turning  are  of  themselves  sufficient  to  indicate  a  central  lesion 
without  an}'  reference  to  the  neurologic  data  in  this  case.  The  absence  of  all 
responses  from  the  right  ear  indicate  a  peripheral  lesion.  This  combination  of  a 
central  and  peripheral  lesion  can  obviously  be  best  explained  by  a  lesion  situated 
in  the  cerebello-pontile  angle. 

The  impaired  nj'stagmus  obtained  on  stimulation  would  suggest  an  involve- 
ment of  the  brain-stem  itself  and  the  definite  impairment  of  past-pointing,  to- 
gether with  the  poor  pelvic  girdle  reactions,  would  similarly  suggest  an  involve- 
ment of  the  cerebellum. 

The  i^atient  was  operated  on  on  March  2.  1915.  and  unfortunately  contracted 
an  inspiratory  pneumonia,  of  which  he  died  a  week  later. 

The  following  is  the  autopsy  report : 

Head. — Upon  removing  the  brain  case  the  meninges  are  taut,  blood  vessels 
congested.     Cutting  through  the  dura  there  is  some  increase  in  the  amount  of  fluid. 


PATHOLOGIC  CASES  ANALYZED 


429 


On  lifting  the  frontal  lolie  to  the  right  side  two  nodular  swellings  are  noticed;  one 
lies  within  the  petrous  portion  of  the  temiioral  bone  in  front  of  the  ridge  of  the 
sella  turcica.  This  nodule  is  about  1.5  cm.  in  diameter,  is  rounded  and  upon  its 
surface  is  covered  by  the  dura,  which  is  perfectly  smooth  over  the  entire  mass; 
apparently  the  tumor  is  growing  between  the  dura  and  the  bony  portion  of  the 


Fig.  129. — Large  cj'st  in  right  cerebello-pcntile  angle. 


petrous.  The  second  nodule  is  larger,  more  rounded,  bulges  more,  is  cystic  to  the 
touch  and  lies  posterior  to  the  petrous  portion  and  beneath  the  tentorium  cerebelli. 
Upon  incising  the  tentorium  in  an  area  between  the  two  tumors  the  knife  appar- 
ently went  through  a  peduncle  with  the  escape  of  fluid,  at  least  an  ounce;  this  fluid 
apparently  coming  from  beneath  the  tumors,  much  more  from  the  larger  one,  in 


430  EQUILIBRIUM  AND  M:RTIG0 

which  it  was  apiiareiitly  uiuler  pressure.  The  seeoiul  tuinoi-.  that  is,  tlie  one  be- 
neath the  tentorium,  was  removed  intact  with  tlie  brain.  Tlie  first  one  in  the  petrous 
portion  was  dissected  out.  This  apparently  occupies  a  position  which  corresponds 
to  the  Gasserian  ganglion  upon  this  side.  It  is  not,  however,  as  near  as  can  be 
made  out  by  dissection,  in  direct  couiiiiunication  witli  any  nerve  trunk.  As  de- 
scribed, it  is  completely  covered  by  dura  ujion  the  upper  surface,  which  is  smooth; 
its  under  surface  is  in  intimate  connection  with  the  bony  i)ortion  of  the  temporal 
bone,  from  which  it  is  necessary  to  free  it  by  cutting,  leaving-  a  ragged  edge  both 
on  the  tumor  and  on  the  bony  portion.  The  tumor  w^as  preserved  in  Ortlrs  fluid, 
half  of  it  u.sed  for  section  and  the  other  half  turned  over  to  Dr.  Spiller. 

Brain. — The  lateral  ventricles  opened  and  choroid  plexuses  removed.  One  sec- 
tion made  through  the  cyst  wall.  This  term  has  not  been  used  before,  but  it 
refers  to  the  second  tumor  described.  In  the  fresh  stage  it  is  seen  that  this  tumor 
is  apparently  a  protrusion  of  the  dura  by  fluid  in  this  position  into  the  cerebello- 
pontine angle.  Here  it  presses  upon  the  cerebellum,  cerebrum  and  upon  the  pons 
and  medulla  oblongata.  While  there  are  a  few  small  adhesions,  it  is  appai'ently 
not  in  intimate  relation  with  any  of  these  structures.  Before  fixing,  the  cyst  was 
filled,  the  ojiening-  tied  off  and  in  its  present  condition  it  is  about  half  its  original 
size. 

Notes  dictated  hij  Dr.  Spiller: 

"The  right  YII  and  YIII  Nerves  are  both  implicated  in  the  wall  of  the  cyst ;  the 
acoustic  more  so  than  the  facial.  The  former  enters  into  the  substance  of  the  cyst 
wall,  while  the  latter  lies  superficially  just  beneath  the  surface  of  the  cyst  wall. 
The  glossopharyngeal  and  vagus  nerves  escape.  Judging  from  the  external  ap- 
pearance of  this  cyst  it  is  merely  a  part  of  a  cystic  degenerated  tumor.  The 
fluid  has  noAv  entirely  escaped  and  palpation  reveals  a  mass  within  the  cyst  that  is 
apparentlj'  tumor.  This  is  of  nodular  formation.  There  is  no  evidence  of  the  V 
Xerve  making  an  exit  from  the  pons.  At  the  part  where  the  nerve  should  leave 
the  iDons  are  strands  of  fibres  spread  out  over  the  surface  of  the  mass  and  having 
the  appearance  of  nerve  fibres.  These  probably  are  fibres  of  the  Y  Nerve.  The 
cystic  tumor  lies  directly  in  the  cerebello-pontine  angle.  This  has  led  to  atrophy 
of  the  anterior  and  lower  part  of  the  right  cerebellar  lo])e  and  to  atrophy  of  the 
right  half  of  the  pons."     (Fig.  129.) 

Case  32. — jMr.  WiUiam  L.  S.,  age  33.  Was  admitted  to  the  University  Hos- 
Ijital  on  October  11,  1915,  complaining  of  blindness  and  headache. 

Three  years  ago  he  was  struck  on  the  head  by  a  l)rick  which  fell  from  a 
scaffold  three  stories  high.  He  was  unconscious  for  about  fen  minutes,  but  then 
went  to  work  and  noticed  no  other  bad  results  of  the  blow.  Two  years  later  he 
began  to  have  attacks  Avhich  he  describes  as  "drawing"  of  the  left  side  of  the 
face.  They  begin  at  the  sterno-clavicular  articulation  and  end  far  up  over  face 
and  forehead.  These  attacks  appeared  once  or  twice  a  day,  lasted  only  a  few 
minutes  and  were  accompanied  by  twitching  of  the  right  upper  and  lower  eyelids. 
Once  or  twice  a  week  he  would  "fall."  This  falling  was  not  to  either  side,  but 
he  just  "crumpled  up."  About  the  same  time  the  eyesight  began  to  fail,  and  three 
weeks  ago  he  became  totally  blind.  Hearing  has  been  poor  in  the  left  ear  for  four 
years.  He  has  not  had  a  drawdng  spell  for  over  a  month.  His  appetite  is  good, 
the   bowels  are  regular.     He  sleeps  pooily.   that    is,  only   a  few  hours   at  a   time. 


PATHOLOGIC  CASES  ANALYZED  431 

Questioning  him  on  another  day,  the  patient  contradicted  his  original  statement 
that  the  attack  began  with  a  drawing  at  the  left  sterno-clavicular  articulation. 
Instead,  he  says  that  these  drawing  attacks  began  in  his  left  cheek. 

Family  history  negative. 

Patient  has  been  married  for  fifteen  years  and  lias  six  children,  all  of  whom 
are  well.     Two  children  died  in  infancy. 

Physical  Examination. — Patient  is  large  and  well  developed.  Gait  and  sta- 
tion fairly  good.  No  Romberg.  No  distinct  weakness  of  facial  muscles.  Tongue 
is  protruded  in  midline.  The  resistance  of  the  patient  to  the  opening  of  his  lids 
is  distinctly  less  on  the  left  eye  than  on  the  right,  and  he  does  not  draw  up  the 
left  corner  of  his  mouth  as  well  as  the  right.  He  wrinkles  his  left  foi-ehead  less 
than  the  right  side  of  the  forehead. 

Eye  Examination  by  Dr.  de  Schweinitz. — Extra-ocular  muscles  normal.  Pupils 
react  to  light  and  convergence.  Right  eye :  Light  perception  only,  chiefly  on 
the  nasal  side.  There  is  apparently  a  subsiding  choked  disc  with  atrophy  in  its 
deeper  layers.  The  arteries  are  small  and  the  surface  of  the  disc  is  raised  three 
diopters.  Left  Eye :  There  is  light  perception,  correctly  projected  on  all  sides. 
There  is  also  choking  of  the  disc,  which  is  apparently  subsiding.  There  are  dis- 
tinct signs  of  atrophy.     Surface  of  the  disc  is  raised  three  diopters. 

Heart  and  lungs  negative.    Mouth  and  throat  negative. 

Upper  extremities  are  well  developed.  No  impairment  of  sensation  to  pain 
and  touch.  The  reflexes,  especially  the  biceps,  are  diminished  on  both  side.  Co- 
ordination is  good  with  the  right  arm,  but  not  so  good  with  the  left.  There  is  a 
distinct  tendency  to  hypometria  with  the  left  hand. 

Lower  extremities.  Power  of  muscles  good.  Sensation  to  pain  and  touch 
normal.  Patellar  reflexes  equally  exaggerated.  Achilles  absent.  No  ankle  clonus. 
No  Babinski.     Many  scars  on  the  ankles  and  feet.     Several  small  chronic  ulcers. 

Wassermann  negative. 

An  X-ray  of  the  skull  shows  that  there  is  possibly  some  depression  to  the 
right  of  the  midline  in  the  vault,  but  this  is  not  definite.  No  evidence  shown  of 
tumor  anywhere. 

Repeated  tests  for  the  corneal  reflex  showed  it  to  be  absent  on  the  left  side 
and  normal  on  the  right. 

The  neurologic  diagnosis  in  this  case  was  a  tumor  of  the  right  cerebral  hemi- 
sphere implicating  the  face  centre. 

An  examination  of  the  vestibular  apparatus  was  made  on  October  20,  1915, 
and  the  findings  presented  on  the  accompanying  chart  (XLV). 

It  will  be  noted  that  the  hearing  in  the  right  ear  is  normal  and  that  the  left 
ear  is  stone  deaf. 

There  was  a  spontaneous  vertical  nystagmus  upward  and  a  spontaneous  past- 
pointing  of  both  arms  to  the  left. 

Turning  to  the  right  produced  a  poorer  and  less  prolonged  nystagmus  than 
turning  to  the  left,  which  indicated  that  the  right  ear  functionated  more  than  the 
left.  Turning  produced  a  past-pointing  of  each  arm  in  both  directions,  which 
suggested  that  the  cerebellar  cortex  was  probably  normal. 


43^2  EQUILIBRIUM  AND  VERTIGO 


CHART  XLV  A 


9f^    ^.^-  Age    33  Dale   (Qc/.Jo,  /^/r. 


Name 

Address 

Referred  by 


DIAGNOSIS; 


SUMMARY: 


Complains  of 


yj  yCM-^tu-A^tyC/    ,Ouu^      'Kfua..dLa.,eJ!jL- 


HISTORY: 

Dizziness    V^-<:-<i-<»-'<!-<_»*oa-^ 
Staggering  ^jL-^JU- 
Deafness   ^    x'.M-    go^     s  <4.u:jia^ 
Tinnitus  / 


NOSE:        A  A-  -X^cx-..^,.«:.c^ 
THROAT:     A^    A^a.u.u.^^UL 

A.  D.         ^A-ij^.oa^    -Kx.^^     v^ 


EARS:  , 

A.  S.     S^Aic-oU.      lU-aJU    >-.^u*^A^ 


Fistula 


Hearing  Tests 


\pli     /l^c-^  A-t^-Jlt-tiA^/    d^-tfji. 


..,^-^ 


Ali.  A,/*  Ac      >     Be      =.      n  Pol.  |  cM  ■^'"**        Galtl/-^ 

Mo  1  o  Ac      ?     Be  n  I  l-«  i 


PATHOLOGIC  CASES  ANALYZED 


433 


CHART  XLV  B 


TESTS  OF  THE  VESTIBULAR  APPARATUS 
SPONTANEOUS 


NYSTAGAroS 
Looking  to  RIGHT  Jh*^^^ 
Looking  to  LEFT     — ^ 
Looking  UP      I 
Looking  DOWN    ->7>v^ 


POINTING 


Shoulder  from  above 


RIGHT 


Nystagmus    t^'^Lu/~*-rTf. ;     t»   ^t^ 
Vertigo  ^„^,^ 

Past-pointing    LtXi.    oAt^-a-    ti    /i/4. 
Falling  ^«,^ 

Romberg    St^^  a^rrx^A.,^ 

Turning  head  to  right     'SAMAA^a^ct^^    A'Tr-OAJc^j-'q . 

Turning  head  to  left  v  0 ,,    f 

Attempt  to  overthrow  iTtjL^^  'q„aJ(jL(.  juct^^CH^^tyt^  J?'^'^ 


LEFT 


To  RIGHT    > 

Amp.  <pA,/^-»UJL 
Duranon  /-^Sec. 


To  LEFT     "k 

Amp.    j> »  A. 
Duration   /VSec. 


TURNING 

I: 

To  RIGHT 

I      Shoulder  from  above 

li 

Nystagmus  /(;<.</<— 1«^ 

Vertigo    A.\JtyOU^  ^  A^^i^*^" /oLuaSXZ&-^<^  ■ 

Past-pointing 


To  LEFT 
Shoulder  from  above 

Nystagmus   v/rWt*!^*:. 
Vertigo    ^^tAAAj^^JL. 
Past-pointing   yht^UuuJL 


A"to/yi 


f-to^^ 


Douche  RIGHT 


-^. 


Amp.  jb^oJUJ^  -a-  £Z^<^teJi, 
After  3j  min.        ser 


CALORIC 

Douche  RIGHT 
Shoulder  from  above 


Head  Back  ^ 

Amp.  ^«A«,j^ 

Douche  LEFT    ?\,<rv-Jt^ 
Amp. 
After    3   min.        sec. 


Head  Back     -yf^ri^/^ 
Amp. 


Nystagmus    A  tAy-i-^AXijL 
Vertigo    /«.«x.^-v.«.-t«*«i>-^ 
Past-pointing    -^aMjCmA. 
Falling     -     '- ' 


Douche  LEFT 
Shoulder  from  above 

Nystagmus    ^h 
Vertigo    J)'..,-LAjt^ 
Past-pointing    -'^ 
Falling      ^.^Vv..^ 


3 "  ^^1^ 


3"to./^.^^- 


cf'to^iSc^'to/fT^^- 


Ou^z<J>^ 


^^U-qlU^ 


(^^tilil/*^ 


'^j:^.^^ 


43i  i:QriLIBRirM  AND  VERTIGO 

] )oii('liiiijj;'  tlie  rij^lit  ear  piodiu-ed  no  iiystji_L;'iiius,  l)iit  did  produce  past-point- 
incr.  On  aiiotlier  exaniiiiatioii  several  days  later  a  iiystaji;-imis  was  produced,  but 
this  iiystaf^uius  was  horizontal  instead  of  rotary.  This  \arial)ility  in  the  res[)onses 
as  well  as  the  presence  of  the  i)erverted  nystagmus  indicated  pressure  against  the 
brain-stcin.  Putting  the  head  l)ac'k  after  doucliing  produced  a  large  hori/ontal 
nystagmus  to  the  left,  with   iiormal   past-pointing  of  both  arms. 

Douching  the  left  ear  wilh  head  upright  and  head  l)ack  produced  no  responses 
whatsoever.  This  suggested  a  complete  destruction  of  either  the  la!)yrintli  or  the 
YIII  Nerve  on  that  side. 

The  following  I'eport  of  the  ear  examination  was  made: 

Left  Ear. —  (1)  Cochlear  fibres  desti'oyed.  No  hearing  whatever.  (2)  All 
kinetic-static  fibres  destroyed.  Douching  all  canals  gave  no  nystagnuis.  vcitigo  oi' 
past-pointing.     The  left  \'II1   Xcrve  or  labyrinth  destroyed. 

Right  Ear. —  (1)  Cochlear  fibres  normal.  (2)  Horizontal  canal  pathways 
normal.      (.'5)  Vertical  canals;  no  reaction. 

Cinirlusiou. — Right  labyrinth,  right  VIII  Nerve  normal.  Right  side  of  me- 
dulla oblongata  normal.     Right  side  of  pons  involved. 

SnninKiri/.- The  l)est  ex])lanation  of  the  above  findings  would  be  a  neoplasm 
of  the  h'fi  cerebello-pontile  angle  pressing  agaitist  the  pons  sufficiently  to  involve 
the  vertical  canals  fibres  from  the  opposite  side. 

Because  this  i-eport  conflicted  with  the  neurologic  diagnosis,  the  patient  was 
again   examined  by  the  neurologic  staff  and  the  following  notes  were  dictated: 

Testing  carefully  for  ataxia  in  the  finger-to-nose  test  fails  to  show  any  reliable 
evidence.  Adiadokokinesis  tested  by  the  revolution  of  the  hand  at  the  wrist  or 
placing  first  the  palm  and  then  the  dorsum  of  the  hand  on  the  thigh  is  entirely 
normal  in  the  left  as  well  as  the  r-ight  hand.  Synergic  movements  in  l)ofh  upper 
limbs  are  entirely  normal;  also  synergic  movements  in  each  lower  limb.  Cerebellar 
catatoriia  may  I)e  present.  Is  able  to  ])i'eserve  the  position  foi-  4  minutes  with 
slight  swaying  toward  the  end  of  the  time.  In  bending  backward  at  the  waist  he 
flexes  his  knees  proportionate  to  the  bending,  in  the  normal  manner.  The  left 
patellar  tendon  reflex  is  a  trifle  prompter  than  the  right.  The  left  Achilles  tendon 
reflex  is  a  trifle  prompter  than  the  right.  Whereas  the  ear  findings  suggest  a  left 
cerebello-pontile  lesion,  other  neurologic  findings  than  those  of  the  Barany  tests 
do  not  confirm  this  localization.  The  Jacksonian  convulsion  with  involvement 
later  of  the  right  eyelid  indicates  a  right  motor  cortical  irritation.  The  left  facial 
paresis  because  of  its  involvement  of  the  upper  branch  of  the  nerv(>  could  be 
cortical  in  origin,  but,  as  it  is  ])robably  not  of  recent  development,  it  is  more 
likely  a  j)eri|)heral  paralysis.  The  examination  suggests  two  lesions,  an  old  one 
in  the  left  cerebello-pontile  angle  likely  to  be  circumscribed  tuberculous  menin- 
gitis and  a  more  recent  lesion  in  the  right  frontal  motor  cortex,  more  irritative  than 
paralyzing.  It  may  be  that  tlieiv  are  adhesions  as  to  the  result  of  the  severe  blow 
and  as  the  result  of  increased  intracranial  pressure  diminishing  the  resistance  of 
the  brain.  This  area  of  cicatrization  is  capable  of  acting  as  an  irritant  focus.  The 
corneal  reflex  on  the  left  side  is  unquestionably  diminished  and  slightly  diminished 
on   the  right.     It  must  be  remembered,  however,   that   there  is  some   weakness  of 


PATHOLOGIC  CASES  ANALYZED  435 

the  left  <jrl)i('ularis  i)alj)ebraruin  so  thai  a  siroiii^er  aCferciii  impulse  from  tlie  con- 
junctiva will  be  necessary  to  cause  contraction  of  tlie  paretic  muscles.  The  re- 
sponse to  tlie  left  orbicularis  palpebrarum  to  sliufht  touch  of  tlie  left  eyelash  is 
exceedincfly  promj)t. 

As  originally  planned,  an  opei'ation  decomprcssiii;;  tlie  right  frontal  lobe  was 
done  on  November  29,  1015,  and  no  lesion  discovered. 

Patient  died  three  months  later  and  autopsy  revealed  a  large  tumor  in  the  left 
i'erebello-i)oiitil(*  angle. 


INDEX 


Italic  figures  In  p<irenthesis  refer  to  Case  nutnhers,  and  Roman  figures  in  pages. 


Abscess,   of  cerebellum,   3()"J 

subcortical,  right  parietal  region,  380 
of  tenipero-splienoitlal  lobe,  3G5,  31)1 
Ampulla,  80 
Auditory  apparatus,  122 

examination  of,  technic  of,  213 
chart  for,  214 
deafness,  2 IS 
dizziness,  2 IS 
ear,  211) 

liearing,  functional  test  of,  220 
nose  and  throat,  211) 
staggering,  218 
tinnitus,  218 
nerve  paths  of,  127 
Auditory  fibres,  128 

nerve,    section    of,    tinnitus    following, 
323 
Aviation,  ear  in  relation  tx),  24 

effect  of,  on  internal  ear,  24 
Aviators,  ear  balance-sense  in,  24 

impairment    of,    a   danger    to    tlie 
service,  31 
equilibration-tests  of,  20 
caloric  test,  28 
falling  test,  27 
for  nystagmus,  26 
past-pointing,  27 
turning-chair,  20 
examination  of,  20 

balance-mechanism,  20 
IT.  S.  A.  examining  centres,  31 
standardization,  20 
of  examiners,  31 
of  tests,  20 
normal    internal    ears    a    requisite    in, 
25 

Balance-mechanism,  in  aviators,  26 

tests  of,  8 
Barany's  caloric  test,  150 

chair  for  turning  tests,  233 

modification  of,  235 
classified  ship  movements,  42 
pointing    tests,    after    ear-stimulation. 
177 
past-pointing,  after  douching,  181 

after  turning,  177 
spontaneous.  10() 
tests  in  intracranial  suigery,  59 
Baresthesia.  90 
"Bilious  attack."  14 
Brain-stem.  01 


Brain-stem,  anatomy  of,  91 

connection  of,  with  cerebellum,  100 
cranial  nerves,  location  of,  in  relation 
to,  98 
medulla  ol)longata,  91 
pons,  95 

Caloric  test,  and  turning  test,  comparison 
of.  257 
in  aviators,  28 
of  Barany,  150 
contraindications  for,  247 
history  of  74 
past-pointing  after,  181 
teciinic  of,  244 
head  backward  00°,  246 
head  forward  30°,  245 
strength  of  stream,  244 
temperature  of  water,  244 
volume  of  water,  245 
in  vertigo,  103 
Catarrlial  deafness,  203 

Central  lesions,  differentiation  from   peri- 
pheral lesions,  294 
locating  of,  within  cranium,  295 
Cerebellar  cortical  re])resentation,  114 
localization,  1 14 

Barany's  experiinents,   117 
peduncles,     functions     of,     theory    of, 
120 
lesions  of,  120 
symj)toms.  120 
right  inferior,  333 
Cerebello-pontile  angle,  cyst  of,  423 
lesions  of,  121,  425,  430 
tumors.   121,  403.  408,  412 
diagnosis  of,  121 
symptoms,  121 
right    side,    involving    cerebellum, 
418 
Cerebellum,  91 

a1)scess    of,    differentiation    from    tem- 

poro-sphenoidal  abscess,  391 
anatomy  of,  100 

connection  of,  with  brain-stem,  100 
cortex  of,  109 
functions  of,  114,  115 
hemispheres  of,  100 
lesion  of,  118 

anterior-superior  portion,  and  brain- 
stem, 20 
both  sides,  369 

437 


438 


INDEX 


C'erehelluiii,  diagnosis  of,   118 

gt'iieral  syiiiptoius,   119 
nujiortam-e  of  all   syinptoins.    118 
tuiiior^.  118 

inferior  lobe,  111) 
su])erior  lobe,  1 19 
lateral  lobes,  119 
veiniis,  118 

and  lateral  lobes,  119 
lirinciples  of,  54 
a  motor  orf;an.  114 
nenronieclianism  of,  114 
relation  of,  to  svnergA-  of  movements, 

118 
right,  abscess  of,  309 
right  lateral  lobe,  cyst  of.  372 
structure  of,  100 

peduncles,  function  of,  113 
middle,  113 
superior,   113 
study  of,  in  relation  to  ear,  91 
tumor  of,  and  pons,  377 
veimis  of,  100 

function  of,  118 
vestibular  nuclei  in,  129 
Cerebral  component  for  nystagmus,  387 
fibres  to  eye-muscle  nuclei,  145 
lesion,  diflerentiation   from  labyrinth- 
itis, 308 
Cerebro-cerebello-spinal  tract,  197 
Cerebrum,   tumor  of  right    hemisphere   of. 
395 
of  riglit  occipital  lobe  of,  398 
Chair.  Harany.  233 

modification  of.  235 
turning.  26 
Chart,  examinations  with  use  of.  249 
caloric  tests,  252  , 

spontaneous  phenomena,  249 
summaries,  value  of.  2fi0 
turning  tests,  249 
Cochlea,  concussion  or  toxsemia  of.  315 
Cochlear   tube,   anatomical   considerations, 

70 
Corpora    quadrigemina.    tumor    at    site   of. 

350 
Crista,  82 
Crossed  past-pointing.  00 

Deafness,  catarrhal,  203 

hysterical,  323 
Deiters'  nucleus.  95 
Dizziness.  12 

Douching,  influence  of.  on   vertical  canals. 
150 

nystagmus  after.  151 

past-])ointing  after,  181 

test,  244 

Ear.  and  aviation.  24 

and  the  neurologist.  53 
and  ordithalmoloirist.  02 
and  the  otf>loirist,  07 


Kar  and  tlie  surgeon,  59 
and  seasickess,  34 
"  balance  '"  portion  of,  4 
examination  of,  accuracy  and  care  in, 
57 
guarding  patient.  258 
in  caloric  test.  258 
in  duration  of  tests.  259 
in  intracranial  disease,  250 
with  patient  in  bed,  200 
rememljering  normal   responses, 

metliod  of,  201 
with  retraction  of  driuniiead,  250 
value  of,  in  neurologic  cases,  53 
internal,  anatomy  of    (see  also  Laby- 
rinth), 76 
examination  of,  67 
advantage  of  stimulation  oxer  other 

methods,  68 
cochlea,  08 

integrity  of,  tests  of,  70 
intracranial  pathways,  07 
physiology  of   (see  also  Labyrinth), 

83 
labyrinth,  acoustic,  83 
"  kinetic.  S3 

static.  83 
lumen   of  horizontal    meinbianoua 
canal,  84 
am|)ulla,  84 
crista,  84 
vertical  semicircular  canals,  84 
practical  uses  of  study  of.  3 
relation  of.  to  equilibration,  4 
routine  methods  of.  68 
sense-organs  of,  anatomy  <if.  81 
crista.  82 
maculla,  81 
organ  of  Corti.  81 
single  test  usually  sufiicient.  09 
surgical  problems  of.  (i9 
kinetic-static  labyrinth  of,  4 

function  of.  4 
as  organ  of  balance,  importance  of.  11 
pathologic    conditions    of,    recognition 

of,  11 
relation  of.  to  cential  nervous  system, 

53 
stinuilation  of.  5 

conjugate    deviation    of    eves    after, 

208 
experimental,  8 
in  ocular  palsies,  63 
reactions  of,  181 
failure  of,  207 
falling,  268 
nystagnuis.  207 
past-])oint  ing.  ■207 
ve7ti'.;o.   207 
nystagmus.  181 
vertigo,  181 
significance  of  responses  to,  50 


INDEX 


439 


Ear  balance-sense  in  aviation,  24 

impairment  of,  a  danger  to  U.  S.  Army 
service,  31 
Ear  study,  value  of,  4  ' 

Ear  tests,  4,  22 

in  aviation,  20 

standardization  of,  2(5 
in    cases    of    eerebcllo-pontile    angle 

growtli,  (iO 
difficulty  of,  (J7 

in  intiammatory  conditions  of  laby- 
rinth, (ii) 
in  intracranial  lesions,  general  prin- 
ciples, 54 
in  intracranial  surgery,  59 
in    lesions    of    Vlli    nerve,    general 

principles,  54 
in  syphilis,  48 

value  of,  in  determining  cure,  52 
in  determining  neural   recur- 
rences, 51 
in  early  diagnosis,  48 
only  means  of  diagnosis,  58 
pliysiological  laws  of,  ()8 
in  spontaneous  nystagmus,  06 
value  of,  1 1 

in    differentiating    labyrinth    and 
intracranial  lesions,  53 
general  princi|)lea,  54 
Eighth  nerve,  anatomy  of,  S2 

and  labyrintii,  anatomic  and  physio- 
logic considerations,  76 
degree  of  function  of,  objective  meas- 
urement, 48 
divisions  of,  128 
auditory  fibres,  128 
vestibular  fibres,  120 

from  horizontal  canal,   129 
froni  vertical  canals,   129 
vestibulocerebellar  tract,  129 
vestibulo-ocular  tract,  129 
fibres  of,    128 

impairment  of,  in  sypliilis,  47 
syphilitic  neuritis  in,  329 
tinnitus  following  section  of,  323 
vestibular  fibres  of,  91 
Electrical  test  of  vestibular  apparatus,  247 
Endolymph,  81 

movement  of,  8 
artificial,  8 
by  douching  ear,  40 
physiology  of,  88 
in  seasickness,  39 
significance  of,  8 
in  vestibular  nystagnuis,  148 
End-organ,  of  cochlea,  82 

of  labyrinth,  81 
End-organs,  impulses  from.  ])livsi(ilngv  of. 

90 
Equilibration,  10,  165 

ear  tlie  chief  organ  of,  4 
the  sense-organ  of,  73 
perfect,  10 


Equilibration,  senses  of,  impairment  or  loss 
of,  11 
compensation  after,  11 
Equilibratory  end-organ,  39 
Equilibrium,  ocular,  dependent  on  ears,  02 
tests  of,  26 
vestibular  tests,  26 
Ewald  experiment,  306 
Eyes,  conjugate  deviation  of,  140,  144 
after  ear-stimulation,  268 
loss  of,  64 

ear  tests  for,  64 
muscles  of,  movements  of,  1^4 
in  relation  to  ear,  62 
Eye-nuiscle  nuclei,  cerebral  fibres  to,  145 
Examination    of   cases    with   use   of   chart, 
249 

Phalli ng.  after  douching,  246 
table  of,  212 
after  ear  stimulation,  203 

absence  of,  208 
after  turning,  243 

table  of,  212 
in  frontal  plane,  210 
in  sagittal  plane,  210 
rule  for,  212 
spontaneous,  20(i 
tests  for,  225 

Barany's  pelviQ  girdle  test,  225 
goniometer,  225 
head  turning,  225. 
Romberg,  225 
test,  225 

in  aviators,  27 
Fibres  of   horizontal  and  vertical   semicir- 
cular   canals,    neuraxial    differentiation, 
361 
Fistula  symptoms, 

nystagmus,   vertigo   and   past-point- 
ing accompanying,  300 
test,  63 
Functional  lesions,  dilTerentiation  of,  from 
organic,  294 

Goniometer,  225 

Hearing,  functional  tests  of,  264 
Randall's,  220 
organs  of,  and  of  balance,  anatomical 
similarity  of,  89 
functional  differences,  89 
Horizontal  canal  tract,  129 

function  of,  138 
Horseley's    screen,    jNIills'    modification    of, 
243 

Intracranial     disease,     differentiation     of, 
from   end-organ   lesion,   424 
examination  of  ear  in,  256 
localization  of,  by  ear-tests,  70 


440 


INDEX 


J,ali\  riiitli.  acmistic,  83 
aiiatdiny  ut,  7tl 
aiiipulla,  SO 
I'orlilcar  tiilio,  Tti 
ciKltilynipli,  Si 
incinhraiiuu.s  .sat',  7t>.  Si 
otolitli  nioiiibrane,  82 
perilymph,  81 
saccule,  81 
seiuichcular  canals,  Tt! 

head  position  in  testing,  78 
tectorial  nienihrane,  82 
utricle.  SI 
vestibule,  7() 
examination  of,  of  \alue  in  sypliilis,  48 
of  central  nervous  system,  49 
in  (letermining  cure,  52 
in  early  diagnosis,  48 
in    estimating    therapeutic    etli- 
cieney,  52 

in  neural  recurrences,  51 
inflammatory    conditions    of,    ear-tests 

in,  C.!! 
impairment  of,  in  syphilis.  47 
kinetic.  83 
kinetic-static,  4 

function  of,  1 1 
lesions  of,  principles  of  diagniosis,  54 
memhranous,  anatomy  of,  81 
calibre  of,  88 
development  of,  81 
physiology  of,  83 

endolvmph  movement,  84.  88 
hair-cells,  83 

inllnence  of  movement,  83 
Avave-im])ulses,  83 
static,  83 

and  VIII  nerve,  anatomic  and  physio- 
logic considerations.  70 
Labyrithine  end-organ.  81 
Labyrinthitis.    difTerentiation,    fiom    cere- 
bral lesion.  208 
from  intracranial  legion.  424 

]\raeula,  81 

]\ral-de-mer  (see  Seasickness),  34 
]\Iedulla  oblongata,  91 
anatomy  of,  91 
nerve-cells  of,  95 
Deiters'  nucleus,  95 
triangnilar  nucleus,  95 
Von  P.echtere\v's  nucleus,  95 
substance  of.  91 
Membrane,  otolith.  82 

tectorial,  82 
M^nit^re's  disease,  38,  425 

symptom-complex,  18 
^^)uth  and  tliroat.  examination  of,  255 

Nausea  of  seasickness,  41 
Nerve   fibres,   cranial,    involved    in    nysfcig- 
mus.  91.98 
eo-oidinat  ion  of.  99 


Nerve  hl)res,  location  of  lesions  involving, 
98 
])osterior  louiiitiidinal   liiindle,  !•!• 
vestibuIo-cerel)ellar  tract.    129 
vestibulo-ocular  tiact,   129 
.\er\ous  system,  relation  of  ear  lo.  5.3 
Neuritis,   svphilitic,    in    both    \' II  I    nerves, 

329 
Neurology,  ear-examination  of   ini|iortance 

in.  53  ' 
Neuro-(!tology.  3 

devtdopnient  of,  73 

i'aranx  "s  contributions.  74 
history  of.  73 
Xosi>,  examin;ition  of.  255 
Nystagmus,  5 

absence  of.  after  ear  stimulation,  2(17 
after  douching.  151 
after  turning,  test  for,  23(1 
of  horizontal  canals,  237 
of  vertical  canals,  273 
components  of.   13() 
ccieliral,  387 

(piick.  cerebral  centre  foi'.  145 
slow.  144 
cranial  nuclei  involved  in,  location  of, 

98 
d\n'  to  loss  of  function  of  ears,  (J2 
»'arpull  of.  138 

endolym])h  movement,   rule   of,    152 
horizontal,  5 

inlluenced  by  fixation  of  eyes.  29 
inverse.  55,  208 
mechanism  of,  145 
pathologic.  200 
])erverted,  55.  208.  340 
])hysiologic,  205 
planes  of,  140 
frontal.   147 
horizontal.   140 
sagittal.  147 

vertical  canals,  relation  of.  to,  140 
|)roduced    bv   artificial    stimulation    of 

ear,  (i2 
recording  of,  after  douching,  252 

after  turning.  249 
rotary.  5 
spontaneous.  04 

determination  of  cause.  00 
ocular,  00 

vestilnilar,  00 
ear-tests,  00 
examination   for.   222 

illumination.  223 
ocular.  (i5 
vertical,  55 
table  of,  after  tuiiiing.  149 
test  for,  IT.  S,  Armv  stamlard,  27 
vestibular,  65,  130' 
definition  of,  130 
endolymph  movement  in,  148 
methods  of  producing,  148 
douchinfr,  150 


INDEX 


441 


Nystagmus,  vestibular,  turning,  148 

nerve    impulses,    tracts    of,   causing, 
LS(i 
iiorizontal  canal,  \'M 

stimulus     awav    from    am- 
pulla, i;5S 
stinuihis    toward    am[>ulla, 
140 
vertical    scmicirt'ular    canals, 
140 
stimulus    away    from    am- 
pulla-,   140 
stimulus  toward,  144 

Ocular  palsies,  63 

car-stimulation  in,  03 

ear  tests  in,  03 

loss  of  conjugate  deviation,  04 
Organ  of  Corti,  SI 

Organic  lesions,  difl'eient iation  from   func- 
tional. 2!)4 
Orientation.  Ki") 
Otolith  membrane,  82 
Otology,  usefulness  of,  4 

Past-pointing,  8 

after  caloric  test,   181 
after  doucliing,  table  of,  203 
after  turning.  177,  241 
Horseley  screen  test,  243 
table  of,  202 
crossed,  00 
explanation  of,  181 

always  secondary  to  verl  igo,  187 
a  cerebral  motor  act,  187 
not  a  cerebellar  function,  187 

ex])erimental  proofs,  187 
failure  of,  after  ear  stinuilation,  207 

significance  of,  117 
in  lesions  of  brain,  .59 
normal,  253 
planes  of,  108 
frontal.  108 
horizontal.   108 
sagitt<al,  198 
rule  for,  212 
Pathologic  cases  analyzed,  204 

abscess,  subcortical,  in  right  ])arietal 
region   {21),  382 
of  temporo-sphenoidal   lobe    (15), 
(2.i),  304.  300 
and       cerebellum,       difTerential 
diagnosis  between  (  /7  ) ,  (23) , 
308.  300 
auditoiy  nerve,  section  of  (0),  319 
cerebellar    lesion,    anterior-superior 
])ortion,  and  brain-stem   (20),  377 
both  sides  (18),  309 
left    lateral    hemisphere     (16), 
365 


I'atliokigic  cases  analyzed,  cerebellar  ped- 
vuicle,     right    inferior,    lesion    of 
{!)),  320 
cerebellar     tinnor     and     tubercular 
meningitis,    dillcrential   diagnosis 
between    (/'/),  3r)0 
cerebello-pontile  angle,  cyst  of  (30), 
423 
lesion  of  (.}/),   i-li),  42."),  430 
result  of  stinuilation  of  vertical 
semicircular    canals    in,    417, 
422 
riulit,  lesion  of,  in\ol\  ing  cere- 
bellum (i.'y),  418 
tumor  of  (,^6'),  (;^7),  (,28),  402, 
407,  412 
cochlea,    concussion   or   toxa-mia  of 

(.',),  315 
fibres    from   horizontal   and   vertical 
semicircular  canals,  neuraxial  dif- 
ferentiation   (11),  340 
IV   ventricle,    pus   and   pressure   of 

(/.7),  304 
hysterical  and  oi-ganic  deafness,  dif- 
ferential diagnosis  of  (7),  323 
internal    ears,    impairment    of     tj), 
31.-) 
both  sides   (5),  318 
intracranial    and    end-organ    lesion, 

dilVcrentiation  between,  424 
labyrinthitis  12),  (S).  308.  .309 

circumscribed    (/),   302 
multi|)le  lesions  in  brain-stem   (13), 

3.V2 
peripheral   and   central   lesions,  dif- 
ferential diagnosis  between    (10), 
330 
pons,   lesion    of,    and   right   cerebral 

crura  (/i),  340 
sarcoma  of  right  motor  region  (22), 

387 
svphilitic     neuritis     in     both     VIII 
■  nerves  (.S).  320 

tumor,    of    both     cerebellar    hemis- 
phei'es,   vermis  and   pons    (10), 
373 
at     site     of     corpora     quadrigem- 

ina   (12),  347 
of  occipital  lobe  of  cerebrum  (2.7), 

308 
of  right  cerebral  hemisphere  (2}), 
.304 
Perilymph,  81 
Peripheral  lesions,  ditTerentiation  of,  from 

central  lesions,  204 
Phenomenon-complex,  290 

cerebellar     peduncle,     right     inferior, 
lesion  of.  297 
right  middle,  lesion  of,  298 
vestibular    nucdei.   right  side,   lesion 
of.  200 
cerebello-ponlil(>   angle,  lesion   in,  300, 
417 


44-2 


INDEX 


PlK'nomeiiont<iiiii>le.\.   lerclnal   iiiua,   liasi- 
of,   lesion   at.  -IW 
Vl\l  nerve  or  laliyrintli.  di'striiction  of, 

2m 

medulla  ol>l('n>iata.  Irsimi  in.  -Jltti 
pons,  near  posterior  luiinlle.  lesion  of. 

297 
posterior    longitudinal    Imndle.    lesion 
of.  21)8 
Pointing,  motor  paths  for,  lS!t 

eerel)ro-terel)ello-sj)inal   or   aconraey 

traet.  lit? 
pyramidal  or  power  traet.   lOG 
spontaneous,  2G(i 
tecbnio  for.  224 
test,  27 
tests  of  Parany.  105 

after  ear  stimulation.  177 
past-pointing,  afti  r  caloiic  test.  181 

after  turning.  177 
recording  of.  after  doueliing.  253 
spontaneous.  Kid 
after  turning.  252 
of  von  Graefe.  1(15 
Pons.  91 

anatomy  of.  92 
inner  structure  of.  95 
lesion  of.  and  riglit  cereln  al  crura.  .340 
posterior  surface  of.  95 
Posterior     longitudinal     bundle     of     nerve 

fibres,  99 
Pyramidal  tract.  196 

Kandall's  functinnal  tests  of  bearing.  220 

Scarpa's  ganglion.  82 
Sclerosis,  multiple,  .35.3 

Screen.    Victor    Horselev.    ^lills'    modifica- 
tion of.  243 
Seasickness,  34.  159 

analogv"   of.   and    internal    ear-disturb- 
ance. 38 
and  labyrintbinc  st inniiatidu.  38 
artificially  induced.  3(5 
doueliing  Ibe  ear,  37 
Barany"s  cdassified  sbip  movemer.ts.  42 
cause  of.  a  pbysiological  pbenomeiion, 

43 
collapse  following,  treatment   <'f.  40 
an  ear  phenomenon,  38 

meclianism  of  production.  39 
etiologA'.  tbeoretic,  34 

cerel>ral  congestion.  35 
cerebral  iscbicmia.  35 
miasmatic  intoxication.  35 
optic  tbeorv.  35 
true,  30 

imnuinity  from.  37.  40 
of  deaf  mutes.  39 
of  infants,  37 
influenced    by    posture    in    lelation    to 
sbip  mfivement,  42 


SeasieUness.   nausea   <>i.  41 
|)redis|)osing  factors,  41 
l)revention  of,  43 
bromides.  44 

elimination  of  nervousness.  44 
gastio-inteslinal  tract.  44 
laliyrintbine  stinuilation.  45 
strontium  salts,  44 
test  of  innnunity,  45 
"  remedies,"  34 
susceptibility  to.  37 
sym]itoms.  3(5 

affected  by  changing  liead   jinsition. 
38 
treatment   of.  4(i 

alkaline  solutions.  40 
lavage.  4(! 
niorpliine.  40 
posture.  4(i 
vomiting  of.  41 
meclianism  of,  40 
Seisestbesia.  90 
Semicircular  canals  of  ear.  anatomy  of,  76 

physiology  of,  89 
Sense,  kinetic-static,  10 
im])ortance  of,  10 
muscle,  joint  and  splanchnic.  ID 
seventh,  10 
sixth,    10 

trilogy  of  equilibration,   11 
Sense-organs  of  internal  ear,  82 
crista.  82 
macula,  81 
organ  of  Corti.  81 
Spiroclueta  ])a]lida  in  central  nerve  lesions, 

50 
Surgery,  relation  of  ear  to.  59 
Sy])bilis,  cerebro-spinal,  52 

im]jortance  of  early  diagnosis,  50 
tests  of  Vill  nerve.  51 
ear  in,  47 
early   diagnosis   of.   48 

of  cential  nervous  system,  49 
ear  examinations,  48 
spirochieta  pallida.  48.  50 
\Vassermaim  test.  48.  49 
impairment,  of  ^'11I  nerve  in.  47 
of  hearing  in.  47 

air-conduction   greater   tl:an   bone 

conduction.  47 
diminished  bone  conduit  ion.  47 
for  high  tones,  47 
of  labyrintli  in.  47 
labyiinf  liine  examination   in,  48 

Tectorial  membrane.  82 
Temporo-sphenoidal  lolie.  abscess  of.  305 
Test,  of  auditory  function   in   sypliilis,  47 
caloric,  28,  244 
historv  of.  74 


INDEX 


443 


Test,    electiiral.    of    vestilmlar    apparatus. 
247 
clei'tiical,  of  ve.stil)iilar  ai)paiatus,  247 
fallinji-,  27.  244 
"  fistula,"  63 

in  intracranial  surgery,  Barany's,  59 
for  nystagnuis,  27 
pelvic  girdle.  Barany's,  225 
Konilierg.  225 
tuning  fork,  of  coclilea.  09 
turning.  'I'.V.i 
Wasserniann,  49,  50 
Tests,  ear.  4 

of  equilibrium,  U.  S.  Arniv  standard, 

26 
past-]iointing.  after  turning,  177 

value  of.  .'52 
pointing.  27.  224 
of  Barany,  165 
of  von  (iraefe,  1()5 
turning.  2(i 

and  caloric,  comoarison  of,  257 
Tinnitus,  etiology  of,  323 

follf)\ving  section  of  VIII  nerve,  323 
Triangular  nucleus,  95 
Tubercular  meningitis.  357 
Turning.  tal)le  of  nystagmus  after,  149 

and     caloric     tests,     comparison      of, 

257 
test.  233 

for  nystagmus,  14S 
Turning-cliair,  '2(> 
Tumors,  of  cerebellum.  US 

in  cerebello-pontile  angle,  00 

ear-tests,  ])henomena  of,  60 

absence  of  responses,  60 

crossed  past-pointing,  00 

involving  cerebellum.  422 

Veutricle.  IV.  99 

anatomy  of,  99 
Vertical   canal,  doucliing,  influence  of,   on, 
■150 
and  nerve  fibres,  course  of,  129 
response  to  stimulation  in  tumors  of 
cerebellar  jiontile  angle,  417 
Vertigo.  12 

absence  of.  after  ear  stinuilation.  267 
after  douching.  163 

subjective    sensations    of,    talde    of, 
1C>3 
after  turning,  161 

subjective  sensations  of,  102 

'  talde  of.  102 
test  for.  241 
caloric  test  in,  163 
causes  of,  13 

classification  of.  15 
lesions  in  ear.  15 
cochlea.  10 
differential  diagnosis,    19 

reported  cases,  19 
external  ear,  15 


\'ertigo,  causes  of,  internal  ear,  infiamma- 
tory,   15 
reported  cases,  16 
non-infiammatory,  15 
middle  ear,  15 
lesions  within  the  brain,  19 
differential  diagnosis,   19 
reported  cases,  19 
ocular  conditions,  19 
toxicmias    affecting    ear-mechanism, 
20 
evanescent,  20 

l)roducing  definite   impairment  of 
internal  ears,  20 
definition  of,  13 
a  distinct  clinical  entity,  13 
an  ear  study,  12,  23 
intestinal  or  stomach,  13 
nerve  tracts  producing,  153 
liorizontal  canal,  153 

stimulus    awav    from    ampulla, 
153 
toward  ampulla,  155 
vertical  canals,  153 

stimulus    awav    from    ampulla, 
155 
toward  ampulla.  157 
quantitative  estimation  of.  30 
spontaneous,   266 

examination  for,  223 
study  of,  10 
a  subject  of  otologA',  70 
systematized,  5,  223 

fundamental  principles  of,  8 
vestiljular,  153 

artificial  production  of,  161 
endolyniph  movements  in,  163 
planes  of.  158 
frontal,  158 
horizontal,  158 
sagittal,  159 
subjective  sensation  of,  rule  of,  163 
Vestibular  apparatus.   122 

examination  of,  teclinic  of,  213 
caloric  test,  244 
difficulty  of,  214 
electrical  test,  247 
falling,  after  turning,  243 
nystagmus,  after  turning,  236 
test  of  horizontal  canals,  236 
of  vertical  canals,  236 
past-pointing  after  turning,  241 
spontaneous  phenoiuena,  222 
falling,  225 
nystagmus,  222 
pointing,  224 
vertigo,  223 
turning  test,  233 
vertigo  after  turning,  241 
interpretation  of  findings  in,  265 
spontaneous  falling,  265 
pointing,  205 
vertigo,  265 


44-t 


INDEX 


\'estiliular    apiiaratus.     lesions    uf,    liypo- 
tlietic-al  cases,  201) 
iiei  \  e    fibres,   central    ilill'eieiitiation 
of,  123 
of  horizontal  canal,  location  of, 

125 
pathways  of,  122 
stimulation  of,  response  to,  123 
of  vertical  canals,  failure  of 

response  to,  123 
theory  of  reactions  to,  125  ~ 
of    vertical    canals,    location 
of,  12(i 
jiaths  of,   12S 
pathological   considerations,   253 

catarrhal  deafness  of  right  ear, 

263 
complete  binaural  deafness,  265 
right    auditory    fibres,    destruc- 
tion of,  204 
tests  for,  204 
inijiairment  of.  264 
word-deafness.  265 
pathways  of,  56 
points  of  lesion,  57 


A'estibular   apparatus,    pathways   of   vesti- 
bulo-cerebello  cerebral  tract,  57 
vestibulo-ocular  tract,  57 
[)ractical  considerations,  255 

examination,     of     mouth     and 
throat,  255 
of  nose,  255 
tests  of,  8 
\'estibular  fibres,   12!i 

impulses,  cortical  center  for  reception 

of,  158 
nuclei  in  cerebelhun,  129 
nystagmus,  130 

symptoms,  difVerentiation  of,  70 
vertigo,  153 

artificial  production  of,  161 
planes  of,  158 
Vestibule  of  ear,  76 
Vomiting  of  seasickness,  41 
von  Bechtere\y's  nucleus,  95 
von  Graefe's  pointing  tests,  165 

Wassermann  test  of  spinal  fiuid  for  cerebro- 
spinal syphilis,  50 
Word-deafness,  205  • 


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